TIC^:)\ 


Fw\ 


GOUT    AND    GOUTINESS; 

AND  THEIR  TREATMENT. 


WORKS  BY  THE  SAME  AUTHOR. 


The    Bronchi    and    Pulmonary    Bloodvessels:    their 

Anatomy    und    Nomenclature.       With  20   illustrations.      Small  4to. 
London  :  J.  and  A.  Churchill. 

Symptoms  and  Physical  Signs:   a  Formulary  for  Clinical 

Note-tnking,  with  examples.     Small  8vo.     London  :  Bailliere,  Tindnll 
and  Co.x. 

How   to    Feel   the  Pulse,   and    what  to    Feel    in    it. 

With    12   illustrations.      Post  8vo.      London  :    Bailliere,  Tindall  and 
Cox  ;  New  York  :  William  Wood  and  Co. 

Cardiac  Outlines  for  Clinical  Clerks  and  Prac- 
titioners. Post  8vo.  London  :  Bailliere,  Tindall  and  Cox  ;  New 
York  :  G.  P.  Putnam's  Sons. 

Heart  Studies,  chiefly  Clinical.  I.  The  Pulse  Sensa- 
tions :  a  Study  in  Tactile  Sphygmolotjy.  London  :  Bailliere,  Tindall 
and  Cox  ;  New  York  :  William  Wood  and  Co. 


Gout  and  Goutiness: 


AND  TH£:iR   TREATMENT. 


WILLIAAI   EWART, 

M.D.  Cantab,  F.R.C  P.  Lond,  M.R.C.S  Eng  , 

PHYSICIAN  TO  ST.  GEORGE'S  HOSPITAL,   AND  TO  THE  BKI.GRAVK  HOSPITAL 

FOR    CHILDREN  ; 

EXAMINER    IN   MEDICINE   AT   THE    CONJOINT   BOARD  ; 

FORMERLY   ASSISTANT-PHYSICIAN   AND   PATHOLOGIST   TO   THE 

BROMPTON   HOSPITAL   FOR   CONSUMPTION. 


NEW  YORK : 
WILIvIAM   WOOD   AND    CO. 

1898. 

{A /I  rights  rfst'1-ved.) 


TO 


WILLIAM  OSLER,   M.D.,  F.R.C.P., 

Professor  of  Medicine  in  the  Johns  Hopkins  University,  and  Physician-in-Chief 
to  the  Johns  Hopkins  Hospital,  Baltimore, 

IM    ADMIRATION    OF    HIS    GREAT    SERVICES   TO    SCIENCE 
AND    TO    CLINICAL    MEDICINE, 

BY   HIS    FRIEND   THE   AUTHOR. 


Digitized  by  tine  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/goutgoutinesstheOOewar 


PREFACE. 

The  renewed  attention  devoted  during  the  last  few  years 
to  the  study  of  gout,  whilst  bringing  us  nearer  to  the 
desired  solution,  has,  for  a  time,  rather  complicated  the 
problem.  The  varied  and  often  conflicting  results  of 
recent  pathological  research  have  had  a  disturbing  effect 
upon  our  therapeutics,  and  further  confusion  has  been 
occasioned  by  the  perplexing  number  of  new  remedies 
claiming  to  possess  chemical  control  over  the  affection. 
A  striking  illustration  of  the  prevailing  uncertainty  is 
furnished  by  the  strange  contrast  between  the  opposite 
methods  which  are  now  put  forward  as  the  rational  treat- 
ment for  gout. 

This  period  of  transition,  although  ill  suited  for  any 
constructive  effort  in  the  direction  of  pathology,  seems  to 
be  an  opportune  season  for  a  reconsideration  of  our 
principles  of  treatment,  and  this  is  the  task  to  which  the 
present  work  addresses  itself.  Since,  however,  a  critical 
study  of  the  therapeutical  questions  inevitably  opens  up 
others  connected  with  pathology,  the  best  introduction  to 
it  will  be  to  review  the  subject  of  gout  in  its  entirety 
rather  than  in  a  fragmentary  fashion. 

In  carrying  out  this  preliminary  inquiry,  a  clear  and 
systematic  account  of  the  views  which  have  been  enter- 
tained, and  of  those  personal  to  the  writer,  has  been  aimed 
at.     All  future  students  of  gout  must  be  indebted  to  Sir 


viii  PREFACE 

A.  Garrod's  great  work,  to  Sir  W.  Roberts'  brilliant  re- 
searches, and  to  the  exhaustive  treatise  by  Sir  Dyce 
Duckworth.  A  prominent  place  belongs  in  these  pages 
to  the  facts  and  to  the  opinions  of  these  authorities. 
They  also  contain  references  to  the  important  works  of 
Ebstein,  of  Lecorche,  and  of  Rendu.  Recent  pathological 
investigations,  of  which  Dr.  Levison's  book  supplies  an 
able  digest,  have  been  noticed ;  and  special  attention  has 
been  devoted  to  the  latest  and  not  least  original  views 
published  in  this  country  on  the  clinical  aspects  of  the 
affection. 

The  treatment  of  gout,  which  is  the  main  subject  for 
study,  has  been  dealt  with  on  the  same  lines  of  systematic 
and,  so  far  as  possible,  practical  exposition.  The  distinc- 
tion between  gout  and  goutiness,  familiar  to  all  observers, 
has  received  special  recognition,  as  one  which  is  essential 
to  clearness  in  all  discussions  on  the  pathology  and  treat- 
ment of  the  affection. 

The  bulk  of  this  volume,  not  the  least  of  its  faults,  is 
partly  explained  by  the  recent  expansion  of  the  literature 
of  gout,  and  by  the  desire — imperfectly  fulfilled — to  deal 
with  it  adequately. 

The  author  is  under  obligation  to  Dr.  Arthur  Herbert 
Hoffman,  of  Old  Burlington  Street,  for  important  sug- 
gestions and  for  his  kind  help  in  revising  the  proofs  ;  and 
to  Mr.  Herbert  G.  Friend  for  valued  and  able  assistance. 


33,  CURZON  Street,  Mayfair, 
September,  1896. 


CONTENTS. 


I. 

INTRODUCTION. 

CHAPTER  PAGE 

I.    GOUT    AND    GOUTINESS   AND   THEIR    MANIFESTATIONS  I 

II.    QUESTIONS    OF   NOMENCLATURE  .  .  .8 

III.  PATHOLOGICAL   QUESTIONS      .  .  .  .12 

IV.  CLINICAL    QUESTIONS  .  .  .  .  l8 
V.    THE   GENERAL   .ETIOLOGY    OF    GOUT    .                  .                  -25 

II. 

THE  THEORIES  OF  GOUT. 

VI.    BRIEF    GENERAL    SKETCH           .                   .                   .  -3^ 

VII.    THE   CHEMICAL   THEORIES        .                  .                  .  -39 

VIII.    THE    MODIFIED    CHEMICAL   THEORIES                   .  .         49 

IX.    THE     HISTOGENOUS    THEORIES,     OR    THEORIES  OF     A 

PRIMARY    PRE-URATIC   TISSUE    CHANGE          .  .          58 

X.    THE    NERVOUS    THEORIES    OF    GOUT     .                  .  .64 

III. 

THE  CHEMISTRY  OF  GOUT. 

XI.    SIR     WILLIAIM      ROBERTS'     INVESTIGATIONS  ON     THE 
PHYSIOLOGICAL  AND   PATHOLOGICAL  CHEMISTRY  OF 
URIC   ACID                   .                  .                  .  .                  .69 
XII.    THE   CHEMICAL    FACTORS    APPLIED  TO  THE  EXPLANA- 
TION   OF   GOUT         .                  .                  .  .                  -78 

XIII.  THE   PATHOLOGY   OF    URIC   ACID            .  .                  .         90 

XIV.  THE    DERIVATION    OF    URIC    ACID           .  .                   -97 


CONTENTS 


IV. 

THE  MORBID  ANATOMY  OF  GOUT. 

CHAPTER  PAGE 

XV.    THE    ARTICULAR    LESIONS    IN    GOUT  .  .       ITO 

XVI.    THE    CARDIAC   AND   VASCULAR   LESIONS    IN    GOUT    .       1 23 
XVII.    THE   VISCERAL    LESIONS    IN    GOUT  .  .  •       I32 

V. 

THE  PATHOLOGY  OF  GOUT. 

XVIII.    URIC    ACID,     THE     LIVER,    THE     KIDNEY,     AND     THE 

NERVOUS    SYSTEM!  ....  14I 

XIX.    THE    MORBID    AFFINITIES    OF    GOUT  .  .  154 

XX.    PLUMBISM    AND    LEAD    GOUT  .  .  .  169 

VI. 

THE  CLINICAL  STUDY  OF  GOUT. 

XXL    THE    CLINICAL    TYPES    AND    STAGES    OF    GOUT  .       180 

XXII.    THE    ACUTE    ARTHRITIC    ATTACK      .  .  .       187 

XXIII.  THE    PROGRESS    OF    GOUT CHRONIC    GOUT    AND 

GOUTY   CACHEXIA  .  .  .  -197 

XXIV.  THE  CLINICAL  FEATURES   OF   GOUT  AND  GOUTINESS 

IN    CONNECTION   WITH   THE   VARIOUS    ORGANS. 

AFFECTIONS    OF    THE    MUCOUS    MEMBRANE  .       205 

XXV.    THE    LIVER    AND    THE    KIDNEY    IN    GOUT      .  .223 

XXVI.    THE    HEART    AND    BLOODVESSELS    IN    GOUT  .       228 

XXVII.    THE     CUTANEOUS     SYSTEM     AND     THE     ORGANS     OF 

SPECIAL    SENSE    .....       235 
XXVIII.    THE    NERVOUS    SYSTEM    IN    GOUT     .  .  .       244 

XXIX.    SIR    WILLOUGHBY    WADE'S    NEURAL    THEORY  .       254 

XXX.    RETROCEDENT    GOUT    AND    WANDERING    GOUT,  AND 

THE    PHENOMENA    OF    IDIOSYNCRASY         .  .       262 

XXXI.  ON  SOME  OF  THE  CLINICAL  PECULIARITIES  OF 
GOUT  AND  GOUTINESS,  GOUTY  INHERITANCF,  AND 
GOUTY    IDIOSYNCRASY       ....       275 


CONTENTS 


VII. 

GENERAL  CONCLUSIONS. 

CHAPTER  PAGE 

XXXII.    CONCLUSIONS    BEARING   UPON   THE   URIC  ACID    AND 

RENAL   THEORY.  ....        282 

XXXIII.  MATERIALS    TOWARDS   A  TROPHIC  THEORY. — GOUT, 

GOUTINESS,    AND    THE    LIVER         .  .  .       2go 

XXXIV.  ARGUMENTS      IN      SUPPORT      OF      THE      '  NERVOUS  ' 

THEORIES. — GOUT   AS   A   TROPHO-NEUROSIS  .       300 

XXXV.    CONCLUDING    PROPOSITIONS  .  .  -310 

VIII. 

THE  TREATMENT  OF  GOUT  AND  OF  GOUTINESS. 

XXXVI.    INTRODUCTORY    REMARKS  .                   .                   .                   -321 
XXXVII.    THE   PRINCIPLES   OF   TREATMENT,  AND  THE  THERA- 
PEUTIC   INDICATIONS    IN    GOUT   AND    GOUTINESS.  331 
XXXVIII.    THE    THERAPEUTIC    METHODS    AND    AGENTS                  .  339 

XXXIX.    THE    MEDICINAL    AGENTS. COLCHICUM         .                   .  346 

XL.    COLCHICUM  :     ITS    INDICATIONS    AND    CONTRA-INDI- 

CATIONS  .  .  .  .  -357 

XLI.    OTHER       MEDICINAL        AGENTS.  THE      ALKALINE 

TREATMENT           .....  364 
XLII.    THE    ALKALINE    SALTS    AND    THEIR    USES    IN    GOUT  376 
XLIII.    THE   SALICYLATES   AND   OTHER   REMEDIES    IN    GOUT  395 
XLIV.    THE    INTERNAL    TREATMENT    OF    ACUTE    GOUT            .  4I2 
XLV.    THE    LOCAL    TREATMENT    OF    ACUTE    GOUT.                   .  419 
XLVI.    THE    TREATMENT    OF    CHRONIC    ARTICULAR    GOUT  .  426 
XLVII.    THE    LOCAL    TREATMENT    OF    CHRONIC    GOUTY    AR- 
THRITIS                    .                   .                   .                   .                   .  443 
XLVIII.    TREATMENT  OF  METASTATIC   GOUT  OF  THE  VISCERA  448 
XLIX.    THE     TREATMENT      OF      GOUTINESS      AND      OF      ITS 

SYMPTOMS  .  .  .  .  -453 

L.    THE    TREATMENT    OF    GOUTINESS     AND     OF     GOUTY 

AFFECTIONS   {continued)  .  ,  .  .      466 


CONTENTS 


IX. 

THE  MEDICINAL  SPRINGS. 

CHAPTER  PAGE 

LI.    THE      TREATMENT      OF      GOUT      AND      GOUTINESS      BY 

MINERAL   WATERS .  .  .  .  -479 

LII.    THE    USES    AND    SELECTION    OF    MEDICINAL    SPRINGS. 

THE    SULPHATED    WATERS  .  .  .       489 

LIII.    THE    USES    AND     SELECTION    OF    MEDICINAL     SPRINGS 

{continued). — the  calcareous  waters    .  .     494 

LIV.    the    uses    and     selection    OF    medicinal    SPRINGS 

{conti?ueed). — the  muriated  waters       .  .     498 

LV.    the    USES    AND    SELECTION    OF    MEDICINAL    SPRINGS 

{contimied). — THE  soDic  carbonated  waters     .     505 

LVI.    CONCLUDING    REMARKS. THE    BRITISH    SPAS  '     .       51I 

X. 

DIET  AND  HYGIENE  IN  THE  PROPHYLAXIS  AND 
TREATMENT  OF  GOUT. 

LVII.    DIET    AND    GOUT  .  .  .  .  •       S'Q 

LVIII.    THE   VARIOUS    CONSTITUENTS    OF    FOOD    IN   THEIR    RE- 
LATION   TO    NUTRITION    AND    TO    GOUT  .  -525 
LIX.    THE    INFLUENCE   OF  DIET   ON   LEUCOCYTOSIS,  AND   ON 
THE  RELATIVE  EXCRETION  OF  NITROGEN,  OF  UREA, 
AND    OF   URIC   ACID                .                  .                  .  -531 
LX.    THE     VEGETARIAN      TREATMENT     AND      THE      '  MEAT ' 

TREATMENT    OF    GOUT  .  .  .  •       53^ 

LXI.    THE    PRINCIPLES    OF    DIET    IN    GOUT    .  .  .       543 

LXII.    THE    DIETARY    AND    ALCOHOL    IN    GOUT    AND    GOUTI- 
NESS ......       549 

LXIII.    HYGIENE    AND    PROPHYLAXIS    IN    GOUTINESS    AND    IN 

GOUT  ......       560 

LXIV.    MUSCULAR     EXERCISE.— MENTAL    WORK. —  REST    AND 

SLEEP  ......       568 


I. 
INTRODUCTION. 


CHAPTER  I. 

GOUT  AND  GOUTINESS  AND  THEIR 
MANIFESTATIONS. 

We  are  still  unacquainted  with  the  nature  of  gout,  one 
of  the  most  ancient  among  the  recorded  diseases  of  our 
race ;  and,  unhappily,  the  difficulties  inherent  to  the 
subject  have  been  complicated  by  those  of  its  nomencla- 
ture, the  term  '  gout '  having  sometimes  been  applied  to 
the  well-known  structural  results,  at  other  times  to  the 
functional  derangement  leading  to  them. 

There  was  a  practical  simplicity  in  the  terminology 
used  by  the  ancients ;  it  had  the  great  advantage  of  clear- 
ness. The  expressions  '  podagra,'  '  gonagra,'  '  omagra,' 
'  chiragra,'  etc.,  indicated  merely  the  seat  of  the  painful 
affection,  irrespective  of  any  constitutional  factor.  The 
substitution  for  this  nomenclature  of  the  single  term 
'  gout '  *  did  not  simplify  matters  ;  it  asserted  the  exist- 

*  Introduced  by  Radulfe  at  the  close  of  the  thirteenth  century. 
Galen  (130—200  a.d.)  had  regarded  the  tophi  as  dried  accumulations  of 
mucus,  gall  and  blood,  and  Paracelsus  (1493 — 1541)  as  a  'mucous 
essence  full  of  earthy  salts,'  a  'Tartarus'  burning  'like  hell-fire.' 
Sydenham's  views  (1624 — 1689)  contributed  no  less  than  subsequently 
the  opposite  doctrine  of  Cullen  to  define  gout  as  a  constitutional 
disease.     For  Sydenham  the  articular  affections  and  the  tophi  were  as 

T 


GOUT  AND  GOUTINESS 


ence  by  the  side  and  independently  of  the  articular  troubles 
of  a  constitutional  disease  which,  even  to  the  present 
day,  it  has  been  impossible  strictly  to  identify,  and  it 
even  suggested  a  theory  as  to  its  nature.  A  great  part 
of  the  literature  of  gout  has  since  then  been  devoted 
to  a  discussion  of  this  supposed  constitutional  disease  ; 
and  its  recognition  is  implied  in  our  present  nomen- 
clature. 

Modern  research  has  once  again  thrown  the  chief  stress 
upon  the  local  changes,  which  alone  are  demonstrable, 
and  for  which  the  strict  use  of  the  term  '  gout '  has  been 
reserved.  Thus,  in  a  limited  acceptation,  which  carefully 
excludes  all  unknown  and  all  theoretical  matter,  '  gout ' 
is  simply  defined  by  Sir  A.  Garrod  as  '  the  group  of 
changes  and  symptoms  connected  with  the  deposition  of 
urate  of  sodium  in  the  joints  and  in  the  tissues.'  An  ex- 
treme development  of  the  same  localizing  tendency  is  that 
which  identifies  the  affection  with  uric  acid,  defining  it 

a  means  of  disposal  for  the  morbid  principle  of  the  disease  —  the 
materia  pecca7is.  Cullen  refused  to  recognise  any  materia  peccans  as 
an  essential  part  of  the  disease,  which  he  regarded  as  one  of  the 
nervous  system,  a  view  which  did  not  enjoy  prolonged  favour. 

The  discovery  of  uric  acid  by  Scheele  (1776),  and  its  subsequent 
recognition  in  tophi  by  Wollaston  (1787),  turned  more  and  more 
attention  towards  the  local  changes,  until  Garrod's  discovery  of  uric 
acid  in  the  blood  as  well  as  in  the  joints  led  to  gout  being  almost 
identified  with  uric  acid  as  the  essential  principle,  and  as  the  agent  in 
its  localization.  Just  as  in  ancient  terminology  gout  did  not  exist 
apart  from  joint  affections,  so  now  the  cry  was,  '  Without  uric  acid,  no 
gout.'  Uric  acid  became,  as  it  were,  a  criterion  for  the  correctness  in  any 
given  case  of  the  term  '  gout,'  which  became  more  closely  reserved  for 
the  varied  manifestation  connected,  or  supposed  to  be  connected,  with 
uric  acid.  An  indirect  result  of  the  growth  of  the  uric  acid  theory  was 
the  comparative  neglect  of  the  constitutional  aspects  to  which  the 
term  '  gout '  was  less  and  less  commonly  applied.  We  shall  see  that 
in  a  certain  measure  this  deficiency  was  supplied  by  the  word 
'  diathesis.' 


GOUT  AND  GOUTINESS 


merely  as  '  uric  acid  in  the  wrong  place,'  and  which 
excludes  the  latent  constitutional  factor  on  the  principle, 
'without  uric  acid,  no  gout.' 

The  interdependence  of  gout  and  of  uratic  deposits  has 
been  less  in  question  than  the  precise  nature  of  their 
relations. 

Gout  is  really  made  up  of  the  '  uric  acid  trouble '  and 
of  '  something  else,'  or,  rather,  in  the  order  of  the  events, 
of  something  concerning  which  we  should  like  to  know 
more  than  we  do,  and,  in  the  second  place,  of  the  uric 
acid  complication. 

Not  many  years  ago  tubercular  phthisis,  in  spite  of  our 
familiarity  with  it  in  every  phase  and  variety,  was  an 
unsolved  problem.  The  results  of  the  disease  were 
obvious  ;  its  essence  entirely  unknown.  This  is  almost 
exactly  our  present  position  towards  gout — much  fami- 
liarity with,  and  some  knowledge  of  its  manifestations, 
but  nothing  known  of  their  original  cause,  from  which 
they  may  differ  as  much  as  tubercle  and  its  life-history 
differ  from  Koch's  bacillus.  What  we  commonly  under- 
stand by  '  declared  gout  '  may  represent  late  results 
only,  having  little  in  common  with  the  fons  et  origo 
mali. 

Phthisis  was  adduced  merely  to  illustrate  the  needful 
distinction  between  the  morbid  agencies  of  a  disease  and 
their  manifest  products.  Nothing  leads  us  to  suspect  in 
gout  a  parasitic  element,  though  others  besides  Boerhaave 
(1668 — 1738)  entertained  the  view  that  it  was  sometimes 
contagious ;  indeed,  whilst  recognising  gouty  morbid 
actions  totally  distinct  from  the  precipitation  of  uric  acid 
with  its  long  train  of  symptoms,  we  hardly  trace  in  gout 
the  complete  outline  of  a  disease.  Neither  need  we 
assume  any  foreign  morbid  material.  A  simple  deviation 
of  the  natural  constituents  of  the  body  from  their  normal 


GOUT  AND  GOUTINESS 


type  and  function  might  explain  all.  We  might  simply 
be  dealing  with  a  disease  of  faulty  nutrition  (using  this 
term  in  its  broadest  sense),  in  which  our  tissues  would 
suffer  in  their  rate  and  mode  of  growth,  of  function,  and 
of  decay.  Gout  might  then  be  regarded  as  one  of  the 
most  striking  instances  of  a  long-continued  functional  dis- 
order, ultimately  ctdminating  in  structural  change  ;  and  of 
the  resulting  product,  the  gouty  subject,  there  might  be 
many  t3^pes,  because  there  are  many  degrees  of  gout  and 
of  goutiness. 

The  more  liberal  use  of  these  terms  has  been  the  out- 
come of  closer  clinical  observation.  The  first  attack  of 
the  toe-ache  marks  a  man ;  not  only  is  he  liable  to  its 
return,  but  during  the  intervals  between  the  attacks  he 
cannot  face  with  impunity  various  risks  to  which  his 
health  was  previously  indifferent.  He  is  henceforth  a 
'  gouty '  person,  and  may  suffer  from  a  variety  of  slight 
gouty  ailments,  even  though  he  may  never  have  another 
severe  fit  of  the  gout. 

An  analogous  case  is  that  of  the  son  of  gouty  parents, 
who  may  present  at  a  relatively  early  period  a  variety  of 
conditions  which  might  be  difficult  to  account  for  without 
a  knowledge  of  the  family  histor}-.  In  a  doubtful  case  of 
this  kind,  where  the  history  cannot  be  obtained,  an  acute 
arthritis  supervening  at  last  would,  as  it  were,  legalize  the 
position  of  the  nondescript  symptoms,  and  confer  upon 
them  a  retrospective  gouty  status. 

Uncertainty  as  to  the  value  of  the  term  is  the  source 
of  practical,  and  of  even  personal,  inconvenience,  not  a 
few  patients  resenting  the  imputation  of  gout  (though  to 
others  the  impeachment  is  welcome)  if  they  should  not 
have  suffered  from  any  local  evidence  of  its  presence  ;  the 
articular  attack,  whilst  it  differs  in  every  point  from  the 
changes  which  lead  up  to  it,  being  rightly  regarded  as  the 


THE  MANIFESTATIONS  OF  GOUT  5 

only  reliable  criterion  for  gout.  Prior  to  the  first  articular 
outbreak,  the  significance  of  the  clinical  events  can  only 
be  guessed,  and  their  cause  is  often  overlooked  or  mis- 
understood. 

THE  MANIFESTATIONS  OF  GOUT. 

The  fact  is,  we  know  gout  only  through  its  manifesta- 
tions. The  local  manifestations,  even  at  their  onset,  are 
bound  up  with  structural  changes,  which  have  supplied 
abundant  material  for  pathological  study.  The  seats  of 
'  local  gout  '  are  varied  ;  it  occurs  in  the  upper  extremity 
or  the  lower,  in  the  larger  joints  or  in  the  smaller  ones, 
though  more  often  in  the  latter ;  it  may  affect  the  external 
ear  with  chalky  deposit,  or  the  palmar  fascia  with  Dupuy- 
tren's  contraction ;  but  in  the  viscera,  except  the  kidney, 
the  local  changes  are  difficult  to  trace,  though  we  occa- 
sionally gain  evidence  as  to  their  situation. 

With  the  general  manifestations  it  is  otherwise ;  for  long 
periods  the  change  is  in  the  function  rather  than  in  the 
structures,  and  the  latter  afford  no  object  lesson  for  the 
pathologist.  Nevertheless,  in  its  ultimate  stages  and  in 
its  gravest  form,  when  it  has  long  been  complicated  with 
the  local  accidents,  '  general  gout '  obtains  full  recog- 
nition. In  the  gouty  cachexia  of  this  stage  structural 
change  is  unmistakably  present ;  but  it  is  of  a  kind  more 
obvious  to  the  eye  in  its  general  aspect  of  decay  than  to 
the  finer  instruments  of  research  in  its  details. 

We  should  not,  however,  assume  that  gout  exclusively 
resides  in  its  structural  manifestations.  A  man  may 
remain  gouty  even  if  some  accident  should  deprive  him 
of  a  limb,  and,  with  it,  of  his  '  local  gout.'  He  will 
not  long  escape  fresh  inroads  and  settlements  of  the 
enemy,  if  he  should  continue  to  neglect  to  guard  against 
its  approach,  nay — sometimes  in  spite  of  vigilance  itself. 


GOUTINESS 


Could  we  but  know  wherein  consists  the  difference 
between  this  man  and  one  in  unshaken  health,  we  should 
know  what  gout  is. 

GOUTINESS. 

We  have  still,  then,  to  deal  with  that  earlier  period  of 
'  general  gout '  which  pathological  anatomy  fails  to  recog- 
nise. That  this  period  is  not  one  of  health,  neither  the 
patient  nor  the  physician  needs  telling;  but  how  soon 
they  may  succeed  in  identifying  the  ill-defined  cause 
depends  upon  their  personal  experience.  A  patient  may 
not  develop  '  local  gout '  until  he  has  passed  through  an 
ordeal  of  symptoms,  which  for  a  time  may  have  afforded 
equal  scope  for  the  shrewdness  of  observers  or  for  their 
scepticism. 

This  important  stage  of  '  general  gout '  is  our  oppor- 
tunity for  that  better  form  of  cure,  prevention.  The 
stage  of  purely  functional  disturbance  possesses  no  strict 
nosological  position,  but  for  clinical  purposes  the  term 
'  goutiness  '  seems  the  most  appropriate.  Goutiness  may 
last  for  long  periods  or  to  the  end  ;  but  its  tendency  is  to 
develop  into  declared  articular  gout. 

The  vagueness  of  the  term  is  not  a  drawback,  in  view 
of  the  ill-developed  character  of  the  conditions  to  which 
it  applies ;  its  comprehensiveness  is  an  advantage,  for 
their  variety  often  includes  minor  local  changes,  such  as 
phalangeal  nodules  or  tophi,  etc.,  the  presence  of  which 
removes  all  doubt  as  to  the  genuinely  gouty  nature  of  the 
rest.  Being  a  purely  clinical  expression,  it  does  not 
appreciably  complicate  the  question  ;  and  whilst  asserting 
the  gouty  complexion  of  the  symptoms,  it  leaves  un- 
touched the  obscure  problem  of  the  antecedents  of  gout 
and  of  the  constitutional  basis  of  the  affection. 

We  may,  then,  bear  in  mind  provisionally  the  following 
varieties : 


GOUTINESS 


I.  Gold  itself,  apart  from  its  manifestations,  or  the  still 
unknown  cause  of  all  gouty  phenomena. 

II.  Declared  gout,  or  gout  associated  with  definite  struc- 
tural change.  This  includes  two  sets  of  phenomena  :  (i) 
The  local  manifestations,  and  in  particular  gouty  arthritis, 
which  may  be  acute  and  temporary  or  chronic  and 
permanent ;  and  (2)  the  general  manifestations,  among 
which  may  be  included  the  acute  visceral  seizures,  but 
which  essentially  consist  of  the  chronic  changes  special 
to  gouty  cachexia. 

III.  Goutiness,  or  the  condition  of  imperfectly  declared 
gout ;  not  necessarily  associated  with  definite  structural 
changes  (though  these  may  also  be  present  in  a  minor 
degree),  and  usually  consisting  of  varied  functional  dis- 
turbances of  a  general  kind  which  set  up  merely  clinical 
symptoms. 


CHAPTER  II. 
QUESTIONS    OF    NOMENCLATURE. 

DIATHESIS,  ARTHRITISM,  HERPETISM. 

The  '  Gouty  Diathesis.'' — Mere  names  cannot  take  the  place 
of  facts.  The  poverty  of  our  vocabulary  simply  reflects  the 
poverty  of  our  knowledge,  and  this  bids  us  to  be  content 
with  the  use  of  the  word  '  gout,'  rather  than  to  risk  con- 
fusion. From  this  risk  the  recently  much  favoured  ex- 
pression '  gouty  diathesis '  is  not  exempt.  Its  lack  of 
definition  and  its  emptiness  have  led  the  present  writer  to 
avoid  its  employment  for  that  of  straightforward  expres- 
sions, such  as  '  disposition  '  and  '  special  liability,'  which 
do  not  tempt  us  to  create  a  thought  to  fit  the  word. 

Various  more  or  less  imaginary  '  turns  or  modes '  of 
constitution,  which  were  formerly  described  as  diatheses, 
have  now  melted  into  thin  air.  The  '  gouty  diathesis,' 
which  is  still  with  us,  has  served  our  literary  convenience 
rather  than  the  interests  of  pathology.  It  reminds  us  of 
those  capacious  brackets  used  by  mathematicians  for  the 
safe  handling  of  unknown  quantities,  except  that  the 
mathematical  formula  works  towards  a  solution,  whilst 
'  diathesis  '  can  only  perpetuate  the  problem.  Whether 
the  word  is  intended  to  express  an  inherited  liability  or 
an  acquired  tendency,  perverting  influences  or  the  re- 
sulting perversion  of  the  constitution,  an  explicit  state- 
ment in  each  case  is  indispensable  for  clearness. 


DIATHESIS,  ARTHRITISM,  HERPETISM  9 

It  might,  in  the  first  place,  be  questioned  whether  a 
diathesis  which  is  acquired  and  that  which  is  inherited 
are  Hkely  to  be  identical.  But  there  are  worse  objections 
than  this.  It  is  a  peculiarity  of  gout  that  it  attacks  indi- 
viduals of  the  most  different  types,  habits,  and  consti- 
tutions, some  of  whom  are  already  the  bearers  of  other 
diatheses.  The  supposed  '  gouty  diathesis  '  cannot,  with- 
out strain,  be  made  to  fit  such  opposites  as  the  over-fed, 
full-blooded,  and  plethoric,  and  the  thin,  half-starved  sub- 
ject, the  scrofulous,  and  the  nerve-ridden  patient.  What 
can  such  extremes  possess  in  common  by  way  of  disposi- 
tion ?  The  wonder  is,  rather,  that  goutiness  should 
develop  in  all  classes  of  subjects,  irrespective  of  undoubted 
constitutional  differences. 

Above  all,  there  is  no  finality  in  the  indulgence  in 
'  diatheses  ';  it  grows  as  a  habit.  Given  an  opening  for 
some  fresh  diathesis,  say  in  connection  with  the  excessive 
excretion  of  uric  acid,  and  a  '  uric  acid  diathesis  '  is  forth- 
with set  up.  Indeed,  this  diathesis  now  claims  the 
domain  of  gout  with  a  title  almost  equal  to  that  of  the 
'gouty  diathesis'  itself.  Yet  the  two  diatheses,  though 
they  largely  overlap,  cannot  be  fused  kito  one.  They  are 
both  distinct  and  well-constituted  '  diatheses.' 

The  '  Uric  Acid  Diathesis  '  embraces  a  great  deal  more 
than  gout,  viz.,  all  other  conditions  in  which  uric  acid  is 
in  excess,  whether  they  are  as  in  gravel,  indirectly  related 
to  gout,  or  as  in  leucocythasmia,  absolutely  foreign  to  it. 
There  is,  at  any  rate,  something  tangible  in  the  uric  acid 
diathesis :  it  implies  a  recognisable  excess  of  a  chemical 
substance  ;  but  the  '  gouty  diathesis,'  if  it  means  anything 
apart  from  inherited  delicacy,  or  from  the  earliest  mani- 
festations of  gout  itself,  is  of  exceedingly  frail  construc- 
tion, and  falls  to  pieces  if  we  endeavour  to  isolate  it  from 
its   bearer.      Doubtless   much    of    the    so-called   '  gouty 


lo  DIATHESIS,  ARTHRITISM,  HERPETISM 

diathesis '  is  nothing  more  than  gout  itself  in  its  earHest 
and  least  obvious  form.  The  confusion  arises  entirely 
from  the  use  of  a  superfluous  word,  which  we  can  well 
afford  to  give  up. 

'  Herpetism'  and  '  Arthritism.' — The  influence  of  names 
in  perpetuating  mere  hypotheses  is  also  shown  in  the  ex- 
tension given  to  the  words  '  herpetism  '  and  '  arthritism,' 
which  have  been  applied  by  French  pathologists  to  sup- 
posed constitutional  tendencies  or  states  distinguished  by 
singularly  vague  outlines.  The  futility  of  this  nomen- 
clature of  the  unknown  is  well  exposed  by  Dr.  Lecorche 
in  his  criticism  of  the  resulting  confusion  of  ideas.* 

*  '  Or,  il  est  devenu  de  moins  en  moins  facile  de  faire  la  lumiere 
dans  le  chaos  nosologique  auquel  les  mddecins  frangais  ont  impose 
cette  etiquette.  Pour  les  uns,  c'est  une  diathese,  une  maniere  d'etre 
de  I'organisme  predisposant  a  certaines  affections  ;  pour  les  autres, 
c'est  une  sorte  de  maladie  gdn^rale  analogue  a  la  syphilis,  par  exemple, 
ayant  des  determinations  multiples  sur  les  muqueuses,  sur  la  peau,  sur 
les  visceres  memes  ;  car  on  decrit  une  bronchite,  une  angine,  une 
entente  arthritique.  Pour  les  medecins  qui  s'occupent  des  maladies 
de  la  peau,  tout  ce  qui  n'est  pas  syphilitique  ou  scrofuleux  est 
arthritique,  et  encore  existe-t-il  des  syphilides  et  des  scrofulides  de 
nature  arthritique.  Pour  les  mddecins  des  stations  hydro-thermales, 
tout  sujet  souffrant  de  douleurs  articulaires,  musculaires  ou  nerveuses, 
est  entachd  d'arthritisme  ;  la  goutte,  le  rhumatisme  aigu,  I'arthrite 
deformante,  les  arthropathies  de  toute  nature,  ils  confondent  tout  sous 
cette  denomination  commode.  Etrange  aberration  d'un  esprit 
remarquable,  Pidoux  considere  ce  beau  desordre  comme  un  effet  de 
Part.  "  La  science,"  dit-il,  "  les  ecoles  sont  aujourd'hui  a  la  distinc- 
tion radicale  du  rhumatisme  et  de  la  goutte  ;  I'art,  au  contraire,  incline 
a  les  croire  congeneres." — PiDOUX,  "  Qu'est-ce  que  le  Rhumatisme  ?" 
Paris,  1 86 1,  p.  31, 

'  Et  nous  ne  parlons  pas  de  ceux  qui,  sous  le  nom  d'herpdtisme,  ont 
voulu  creer  une  nouvelle  variety  d'etat  diathesique,  varidte  dont  les 
caracteres  sont  tellement  semblables  aux  manifestations  assignees  a 
I'arthritisme  que  les  eleves  meme  de  Bazin  ont  renoncd  a  faire  la  dis- 
tinction. 

'  On  voit  que  le  mot  chaos  est  le  terme  juste  pour  caractdriser  une 
pareille  situation.     Comment  y  faire  la  place  de  la  goutte  ?     La  goutte, 


DIATHESIS,  ARTHRITISM,  HERPETISM  u 

With  the  help  of  a  name  these  pure  concepts  acquire  an 
appearance  of  reahty,  and  further  generahzations  are 
based  upon  them.  We  find  ourselves  passing  from  the 
substantive  to  the  adjective  case,  an  '  arthritic  '  or  '  her- 
petic '  quality  being  described  even  in  symptoms  and  con- 
ditions not  connected  with  the  joints  or  with  the  skin  ; 
and  we  are  raised  at  one  step  to  the  height  of  abstraction 
when  we  are  told  that  '  arthritism  '  may  exist  without  any 
joint  trouble,  and  '  herpetism  '  without  any  skin  affection. 
We  agree  with  Lecorche  that  '  chaos  '  is  the  only  word 
applicable  to  the  result.  The  disappearance  of  the  three 
names  which  head  this  chapter  would  be,  in  the  writer's 
opinion,  an  unqualified  gain. 

c'est  Tarthritisme,  disent  les  uns  ;  la  goutte  est  une  branche  de 
Tarthritisme,  disent  les  autres.  La  goutte  et  le  rhumatisme  sont  les 
deux  embranchements  d'un  meme  tronc,  qui  est  I'arthritisme,  dit 
Pidoux.  Qu'on  definisse  d'abord  Tarthritisme ;  on  pourra  discuter 
ensuite.  Pour  nous,  en  attendant,  la  goutte  est  une  maladie  qui  se 
differencie  des  autres  maladies  a  manifestations  articulaires  par  un 
exces  d'acide  urique  dans  le  sang  et  dans  les  tissus,  et  elle  n'a  aucune 
analogic  avec  le  rhumatisme,  maladie  infectieuse.' — '  La  Goutte  et  les 
Maladies  Assocides.'     Paris,  1884,  p.  425. 


CHAPTER  III. 

PATHOLOGICAL   QUESTIONS.— GOUT   AND 
METABOLISM. 

Any  attempt  to  define  the  word  '  gout '  inevitably  brings 
up  the  following  questions  : 

1.  Does  there  exist  in  those  whose  joints  suffer  the 
changes,  which  all  are  agreed  to  call  gout,  any  consti- 
tutional morbid  process  capable  of  arising  or  of  persisting  in- 
dependently of  the  articular  trouble  ? 

2.  If  any  such  independent  morbid  process  exists,  to 
what  extent  can  it  claim  to  be  regarded  strictly  as  a  disease  ? 

3.  What  is  its  relation  to  the  joint  trouble — that  of  a  cause, 
a  complication,  or  a  result  ?  If  it  be  the  cause  of  the 
arthritis,  should  it  not  be  regarded  as  the  chief  part — nay, 
the  essence  of  gout  ? 

In  simpler  terms  :  Is  gout  merely  a  local  affection,  and 
are  we  to  restrict  the  use  of  the  term  to  the  attack  of  pain 
and  of  swelling  ?  Or  is  it  essentially  a  constitutional 
affection  with  local  complications  ?  If  so,  has  it  any 
separate  existence  apart  from  changes  in  the  joints  ?  Can 
it  exist  in  a  patient  in  the  intervals  between  the  articular 
seizures  long  before  their  first  appearance,  or  long  after 
their  cessation  ?  Lastly,  what  name  should  be  applied 
to  it  ? 

Slender  as  is  the  pathological  support,  we  can  hardly 
exclude  the  notion  of  a  general  and  constitutional  affection. 


GOUr  A  PERVERSION  OF  NUTRITION  13 

Our  medical  language  betrays  the  impression  that  there 
is  a  constitutional  background  for  the  local  events.  We 
speak  of  the  manifestations  of  gout.  Again,  such  terms  as 
'latent,'  ' retrocedent,'  'suppressed,'  'and  'visceral'  gout 
can  only  apply  to  some  internal  affection.  Swollen  joints 
are  not  inherited,  but  we  say  of  gout  that  it  is  hereditary. 
The  word  '  diathesis '  also  conveys,  though  in  a  nebulous 
form,  the  same  interpretation. 

The  clinical  evidence  in  favour  of  the  existence  of  a 
constitutional  aspect  of  gout  will  probably  be  regarded  as 
sufficiently  strong  to  compensate  for  the  almost  negative 
pathological  evidence.  Constitutional  gout  often  exists 
apart  from  its  articular  manifestations,  which  may  not 
evolve  till  late,  or  even  at  all.  The  verbal  difficulty  which 
this  admission  implies  may  be  lessened  by  the  use  of  the 
term  '  declared  gout '  for  all  cases  in  which  the  articular 
complication  is  developed  ;  whilst  '  goutiness '  would  con- 
veniently express  the  varied  constitutional  disturbances 
not  associated  with  articular  mischief,  which  are  in  many 
subjects  the  alternative  expression  taken  by  the  affection. 

GOUT  A  PERVERSION  OF  NUTRITION. 

The  skin  of  gouty  people,  their  tissues,  the  incidents  in 
their  clinical  history,  and  their  functions,  particularly 
those  of  the  nervous  system,  all  tell  the  same  tale  of 
delicacy,  vulnerability,  and  excessive  response  to  stimu- 
lation. The  change  is  a  pervading  one.  The  skin 
is  thin  and  vulnerable ;  the  mucous  membranes  frail 
and  irritable  ;  the  nervous  system  quick  and  excitable. 
Yet  we  do  not  attempt  to  localize  the  disease  in  connec- 
tion with  the  skin,  with  the  mucous  membranes,  or  with 
the  nervous  system.  The  condition  is  one  affecting  the 
entire  body  and  each  cell  within  it,  even  the  germ-cells 
sharing    in   the   alteration,    and   transmitting    it    to   the 


14  GOUT  A  PERVERSION  OF  NUTRITION 

offspring.  So  general  a  change  can  only  be  due  to  a 
deep-seated  process  affecting  metabolism  itself. 

Metabolism. — The  simple  word  '  metabolism  '  *  conveys 
to  the  trained  mind  the  idea  of  a  complex  and  unceasing 
exchange  between  the  component  parts  of  the  organism, 
which  is  the  material  basis  of  life.  In  a  restricted  sense 
it  is  the  chemical  interaction  between  the  living  cell- 
substance  and  the  soluble  substances  and  juices  supplied 
from  the  blood  to  permeate  the  spongy  cellular  structure, 
and  ultimately  to  be  gathered  again  into  the  blood 
through  the  lymphatics. 

Metabolism  is  the  agent  of  growth  and  of  decay  ;  in  tech- 
nical language,  it  is  both  '  constructive  '  and  '  destructive.' 
Both  operations  are  simultaneous,  one  set  of  substances 
being  built  up,  the  other  broken  down.  The  balancing 
of  these  two  linked  processes  constitutes  the  perfection  of 
health  ;  their  complete  arrest  is  equivalent  to  death ;  their 
undue  acceleration  or  delay,  or  their  deviations  from  the 
normal  type,  meaning  disease. 

Leaving  aside  the  comparatively  coarse  accidents  which 
may  befall  the  adjustment  of  the  supplies,  and  their 
eventual  absorption  and  assimilation,  the  much  finer  and 
more  intimate  elaborations  which  constitute  metabolism 
proper  are  essentially  of  the  nature  of  oxidations.  The 
diseases  characterized  by  faulty  metabolic  processes  form 
a   group   to  which   the    name  of  nutritional   diseases  or 

*  This  is  an  instance  of  the  convenience  of  a  dead  language 
in  science.  The  word  '  metabolism '  is  Greek— nearly  all  our  old 
medical  words  have  been,  and  all  our  new  words  year  by  year 
are  taken  from  the  Greek.  Yet  Greek,  hitherto  an  ornament  and  an 
element  of  culture,  and  now  more  than  ever  an  intellectual  necessity, 
is  taken  away  from  us,  and,  in  the  name  of  educational  progress,  the 
great  body  of  the  profession  is  cut  off  from  the  sources  of  medical 
nomenclature,  and  from  an  intelligent  use  of  its  own  technical  terms. 
Can  this  policy  be  right  ? 


LESSENED  TISSUE  RESISTANCE  15 

diseases  of  metabolism  is  properly  applied,  and  to  these 
belong,  among  others,  gout  and  obesity. 

In  some  of  the  peculiarities  of  both  affections  we  trace 
indications  of  a  slowing  rather  than  of  an  acceleration  of 
the  metabolic  changes.  This  view  has  been  ably  put 
forward  by  Professor  Beneke,  and  subsequently  by  Pro- 
fessor Bouchard,  under  the  significant  titles  of  '  maladies 
par  ralentissement  de  la  nutrition '  and  of  '  nutritions 
retardantes.'  But  it  would  be  rash  at  this  stage  to 
dogmatize  on  so  abstruse  a  subject.  We  must  bear  in 
mind  that  the  fault  may  be  not  so  much  in  the  rate  as 
in  the  direction  which  metabolism  may  assume.  In  the 
end-products  we  certainly  have  to  deal  with  errors  in  pro- 
portion— too  much  fat  in  one  case,  too  much  uric  acid  in 
the  other.  This  would  rather  suggest  a  deviation  from  the 
normal  chemical  routine  than  a  mere  alteration  in  its  rate. 

LESSENED  TISSUE  RESISTANCE  IN  GOUT. 

As  regards  function,  the  direct  outcome  of  this  intimate 
derangement  of  nutrition  is  a  lowered  resistance  of  cells, 
tissues,  and  organs.  Gout  is  evidently  a  disease  of 
diminished  resistance,  and,  in  that  sense,  of  debility — an 
important  point  to  be  remembered  in  connection  with 
treatment. 

In  the  individual  case  the  resistance  may  be  diminished 
in  some  special  direction,  i.e.,  one  organ  or  system  may 
be  specially  susceptible,  and  the  goutiness  will  then  lead 
to  well-defined  symptoms  ;  or  it  may  remain  widely  distri- 
buted, without  special  localization,  and  ill  defined  in  its 
manifestations. 

The  joints  stand  out  among  all  other  tissues  as  least 
resistant  to  the  gouty  influence.  Their  susceptibility  is 
characteristic  of  gout,  though  it  cannot  be  regarded  as  an 
exclusive,  universal,  or  absolutely  essential  feature.    Their 


i6         EVOLUTIONARY  OR  PRE-ARTHRITIC  STAGE 

loss  of  functional  resistance  is  shown  in  their  inability  to 
resist  the  deposition  of  the  urates.  The  uratic  infiltration 
of  those  joints  which  for  reasons  unknown  are  specially 
prone  to  suifer  is  the  most  striking  pathological  aspect 
of  gout.  The  tendency  to  abnormal  accumulation  and 
deposition  of  uric  acid,  though  pre-eminently  localized  in 
the  joints,  is  a  general  feature  of  gout ;  whilst  uric  acid 
itself  is  apparently  a  by-product  of  the  special  perversion 
of  nutrition  originally  mentioned. 

THE  EVOLUTION  OF  GOUT,  AND  THE  EVOLUTIONARY 
OR  PRE-ARTHRITIC  STAGE. 

The  distinction  which  has  been  suggested  under  the 
names  '  gout '  and  '  goutiness '  between  two  degrees  or 
varieties  of  the  affection  is  not  unsupported  by  facts.  In 
a  large  number  of  subjects,  including  many  who  inherit 
gout,  the  joint  troubles  and  the  uratic  deposition  are  but 
slight,  or  occur  late ;  whilst  the  general  constitutional 
features  assume  prominence.  In  acquired  gout,  the  arti- 
cular and  the  uratic  manifestations  are  almost  invariably 
the  first  to  appear,  and  most  commonly  their  advent  is 
acute  and  unexpected. 

In  the  other  set  of  cases  the  arthritic  development  is 
manifestly  worked  up  to,  and  gradually  evolved.  The 
joints  escape  for  a  time  whilst  gouty  mischief  is  astir 
elsewhere.  This  stage  of  gout  may  aptly  be  designated 
as  the  pre-arthritic  stage.  Its  often  considerable  duration 
and  the  gouty  character  of  some  of  the  events  within  it 
might  lead  us  to  regard  it  as  part  of  the  pathological 
history  of  all  gout,  and  to  expect  some  analogous  evolu- 
tionary period  in  all  other  instances  also  ;  but  in  acquired 
gout,  if  it  exists  at  all,  the  pre-arthritic  stage  is  certainly 
not  manifest.  Further  reference  will  be  made  to  this 
subject  in  the  Clinical  Section. 


EVOLUTIONARY  OR  PRE-ARTHRITIC  STAGE         17 

Declared  arthritis,  then,  should  it  supervene,  serves  as 
a  clinical  test  for  the  gouty  nature  of  any  antecedent 
abarticular  phenomena.  The  familiarity  which  may  thus 
have  been  gained  with  the  latter,  aided  by  the  family 
history,  enables  experienced  physicians  to  identify  their 
character  almost  with  certainty,  even  in  the  absence  of 
the  criteria  of  articular  gout.  Cases  of  this  kind,  formerly 
described  as  '  incomplete  gout,'  throw  light  upon  the 
natural  history  of  the  affection.  Its  development,  in  a 
large  number  of  instances,  is  not  sudden,  and  its  localiza- 
tion in  the  joints  may  be  long  delayed.  Meanwhile, 
general  changes  occur  imperceptibly,  which  at  first  are 
more  difficult  to  seize  upon  because  not  confined  to  any 
locality  ;  but  the  general  aspect  of  '  goutiness '  does  not 
long  escape  recognition  by  the  expert,  and  it  conveys  the 
undoubted  impression  that  the  general  nutrition  has 
suffered,  a  conclusion  which  becomes  obvious  to  all  in 
the  extreme  condition  known  as  '  gouty  cachexia.' 


CHAPTER  IV. 
CLINICAL  QUESTIONS. 

THE  RELATIVE  PREVALENCE  OF   GOUT  AT  THE  PRE- 
SENT TIME.— THE  ATTENUATIONS  OF  GOUT. 

Peculiar  interest  attaches  to  the  question  whether  gout 
has  shown  any  variation  in  its  type  since  the  earHest 
times,  and  what  differences  may  be  traced  between  gout 
in  former  days  and  the  affection  such  as  we  now  witness 
it.  The  geographical  or  chmatic  and  the  ethnical  factors 
in  disease  have  received  increasing  attention ;  but  a 
systematic  study  of  the  variations  wrought  by  the  pro- 
gress of  time  has  yet  to  be  undertaken. 

Gout  is  certainly  as  ancient  as  civilization ;  and  so  far 
as  we  can  identify  them  in  the  accounts  handed  down 
from  remote  ages,  the  aetiology,  the  leading  symptoms, 
and  the  outward  characters  of  the  articular  gout  of  the 
ancients  were  practically  the  same  as  belong  to  gout  in 
our  own  times  ;  but  of  its  relative  prevalence  in  antiquity 
we  have  no  means  of  judging.  The  ultimate  lesions  of 
gouty  arthritis  and  its  pathology  are  presumably  as  im- 
mutable as  those  of  osteo-arthritis,  a  disease  the  charac- 
ters of  which  may  be  studied  in  specimens  which  have 
reached  us  from  prehistoric  times,  and  the  same  is  pro- 
bably true  of  any  visceral  lesions  akin  to  the  arthritic. 

Nevertheless,  that  minor  changes  may  have  occurred 
with  the  lapse  of  time  there  is  good  reason  to  believe. 


CONTEMPORARY  GOUT  AND  GOUTINESS  19 

Indeed,  they  may  be  expected  in  a  disease  essentially 
conditioned  by  the  mode  of  life.  In  its  clinical  types,  in 
its  duration,  and  in  its  relative  mildness  or  severity,  there 
is  room  for  much  variation.  Whilst,  then,  the  essential 
pathological  features  are  probably  the  same  now  as  ever 
they  were,  all  the  rest  in  gout  is  variable,  and  more  especi- 
ally the  mutual  relation  and  degrees  of  the  two  phases. 

The  history  of  ahavticular  gout  in  the  distant  past 
cannot  be  traced  with  any  certainty  ;  but  in  connection 
with  less  remote  periods  the  inquiry  can  be  conducted 
with  some  definiteness,  and  it  possesses  practical  interest, 
since  the  remedies  and  the  doses  used  by  our  fore- 
fathers might  not  be  necessarily  suitable  for  the  present 
generation. 

CONTEMPORARY  GOUT  AND  GOUTINESS. 

Gout  being  to  a  large  extent  a  manufactured  product 
of  civilization,  and  being  influenced  more  than  most  other 
affections  by  inheritance,  conditions  of  life  capable  of  im- 
pressing peculiarities  upon  the  organism  may  be  expected 
to  affect  in  a  direct  manner  the  liability  of  subsequent 
generations.  The  modifying  influences  special  to  modern 
times  can  only  be  briefly  indicated.  Our  luxuriousness  of 
living  vies  with  that  to  which  the  gout  of  the  ancients  has 
been  attributed ;  but  in  addition  profound  changes  have 
taken  place  in  the  social  and  economical  conditions  of  the 
last  few  generations,  none  of  which  is  probably  so  im- 
portant in  connection  with  gout  as  the  agglomeration  of 
the  population  in  large  towns. 

Moreover,  the  present  century  has  called  into  operation 
previously  latent  forces  of  Nature.  The  scheme  of  life  is 
complicated  by  new  agencies  ;  the  storage  and  the  libera- 
tion of  nerve  energy  are  both  altered  in  their  rate  and  in 
their  amount ;  wear  and  tear  which  is  saved  by  anaesthetics 


20  CONTEMPORARY  GOUT  AND  GOUTINESS 

and  narcotics  is  hastened  by  steam  and  electricity.  Our 
habits  and  occupations,  our  expenditure  of  energy,  our 
food,  have  all  undergone  alterations.  In  a  word,  the 
artificial  conditions  which  tend  to  modify  the  reaction  of 
the  organism  have  grown  at  a  rate  previously  unexampled  ; 
and  although  it  were  difficult  to  prove  that  we  differ  in 
any  wide  measure  from  generations  which  have  preceded 
us,  a  belief  prevails  that  in  certain  directions,  particularly 
in  that  of  the  nervous  system,  the  influence  of  our  sur- 
roundings has  not  been  inoperative,*  and  that  the  quality 
of  the  vital  reactions  to  stimulation  has  undergone  slight 
modifications. 

Passing,  however,  from  this  large  and  debatable  subject, 
we  may  point  to  definite  influences  modifying  in  a  calcu- 
lable degree  the  prevalence  and  the  type  of  the  affection. 
Indeed,  within  the  recollection  of  those  who  can  look 
back  far  enough,  perceptible  changes  have  taken  place  in 
the  prevalence  of  gout,  in  the  type  of  the  gouty  attack,  and 
in  the  peculiarities  of  the  gouty  state. 

THE  ATTENUATION  OF  ACQUIRED  GOUT. 

The  relative  prevalence  of  each  of  the  diseases  of  middle 
age  is  now  increased  by  the  accession  of  lives  such  as  were 
previously  cut  short  by  typhus,  typhoid,  diphtheria,  etc. 
Thanks  to  modern  hygiene  and  preventive  medicine,  the 
gouty  period  of  life  is  now  reached  by  these  vulnerable 
constitutions,  among  whom  many  are  prone  to  goutiness 
or  the  bearers  of  a  gouty  inheritance,  and  therefore  likely 
to  establish  a  gouty  posterity. 

The  type  of  the  affection  has  also  been  exposed  to  modi- 
fying influences  in  the  individual  and  in  the  race.     The 

*  The  views  of  Dr.  Pye-Smith,  which  differ  slightly  from  the  above, 
might  be  read  with  interest.  Cf.  Lumleian  Lectures  on  Etiology  : 
Harveian  Oration  and  Memoir.     London  :  J.  and  A.  Churchill,  1895. 


ATTENUATION  OF  ACQUIRED  GOUT  21 

diffusion  during  the  two  last  generations  of  sounder  views 
on  hygiene  and  diet  must  have  checked  the  severity  of 
acquired  gout,  as  well  as  the  strength  of  the  predisposition 
transmitted  to  the  offspring.  Among  the  classes  most 
liable  to  the  disease,  a  broader  appreciation  of  the  evils  of 
gout  has  led  to  greater  prudence  in  respect  of  food  and 
beverage.  A  great  share  in  this  result  is  doubtless  due  to 
the  enlightened  action  of  the  profession,  whose  almost 
unanimous  advice  in  respect  of  the  rules  of  diet  has  ob- 
tained increasing  attention. 

Observation  confirms  the  correctness  of  this  surmise. 
Physicians  of  mature  experience  no  longer  witness  the 
violent  attacks  of  gout  with  which  they  had  been  familiar 
in  their  earlier  days.  On  the  other  hand,  they  can  trace 
no  decrease,  but  rather  an  increase,  in  the  prevalence  of 
goutiness — if  under  that  conveniently  vague  and  compre- 
hensive term  we  include  those  unstable  states  and  those 
ill-developed  manifestations  for  which  it  would  be  hard  to 
assign  a  nosological  position  except  under  the  heading  of 
gout. 

THE  ATTENUATION  AND  THE  FREQUENCY  OF 
GOUTINESS. 

This  change  to  a  milder  type  has  not  been  confined  to 
the  articular  seizures  of  acquired  gout.  With  an  increased 
prevalence,  or,  at  any  rate,  with  an  increased  recognition 
of  the  abarticular  forms,  we  note  also  their  lessening 
severity.  A  larger  proportion  of  cases  present  mere 
attenuations,  not  always  gouty  at  first  sight,  but  readily 
identified  as  such  in  connection  with  their  attendant 
circumstances,  with  their  exciting  causes,  with  their 
occurrence  at  certain  seasons,  with  their  retinue  of 
collateral  affections,  and  with  the  constitutional  aspect 
of  the  patients.     Without  these  helps  many  a  case  might 


22      ATTENUATION  AND  FREQUENCY  OF  GOUTINESS 

be  overlooked.  In  certain  families  some  members  inherit 
gout  badly,  others  slightly,  others  not  at  all ;  the  slighter 
degrees  of  inheritance  are  perhaps  observed  with  in- 
creasing frequency,  and  goutiness  is  becoming  relatively 
more  common  than  declared  gout. 

In  this  circumstance,  and  in  the  general  mitigation  of 
all  the  arthritic  manifestations,  we  see  a  hopeful  sign. 
The  possibility  of  an  ultimate  extinction  of  the  bias  in 
gouty  families  is  denied  by  some  authorities,  but  we 
should  not  forget  that  by  the  side  of  the  tendency  to  a 
reproduction  of  morbid  parental  peculiarities  there  is  a 
yet  stronger  tendency  in  Nature  to  reproduce  the  healthy 
type  of  the  race  in  each  successive  generation. 

Meantime,  one  of  the  features  of  contemporary  practice 
is  the  prominence  allotted  to  the  gouty  factor,  and  the 
frequency  with  which  it  is  held  to  complicate  or  modify 
other  affections. 

The  tendency  to  attribute  to  gout  a  variety  of  ailments 
of  an  obscure  complexion,  arising  in  those  likely  by  in- 
heritance or  by  habit  of  life  to  be  eventual  victims,  is  by 
no  means  novel.  Even  forty  years  ago  many  diseases 
whose  clinical  features  are  now  quite  familiar  were  in  those 
days  unknown.  Strange  symptoms  had  to  be  explained 
under  some  of  the  available  heads  of  disease,  and  gout  came 
in  for  a  large  share  of  vicarious  responsibility.*    Errors  in 

*  Even  so  recently  as  1854  Sir  Spencer  Wells  wrote  as  follows  in 
his  '  Practical  Observations  on  Gout  and  its  Complications,  and  on  the 
Treatment  of  Joints  stiffened  by  Gouty  Deposits'  (John   Churchill, 

1854)  : 

'  Any  attempt  to  describe  the  nervous  diseases  of  females  caused 
by  gout  would  lead  to  an  enumeration  of  almost  all  forms  of  their 
diseases,  especially  those  usually  considered  as  hysteric.  The 
intestinal  derangements,  with  tympanitis,  neuralgia,  or  colic,  the 
hysteric  pain  in  the  right  epigastrium,  the  cardialgia  and  gastrodynia, 
the  hysteric  vomiting  and  epigastric  spasms,  the  morbid  sensibility  of 
the  pharynx  and  fauces,  hysteric  palpitation,  asthma,  or  bronchitis, 


ATTENUATION  AND  FREQUENCY  OF  GOUTINESS      23 

diagnosis  are  probably  much  less  common  nowadays ;  at 
any  rate,  the  reproach  of  unduly  extending  the  domain  of 
gout  is  much  less  deserved  by  the  present  than  by  former 
generations  of  physicians.  Many  of  the  affections  which 
Musgrave  and  his  successors  described  as  gout  are  now 
identified  as  separate  organic  or  functional  diseases. 

The  converse  is  also  true,  though  probably  in  a  less 
degree.  The  gouty  character  of  not  a  few  affections  may 
have  been  overlooked  in  the  past,*  and  instances  of  the 
same  oversight  are  not  unknown  in  contemporary  practice. 

loss  or  alteration  of  the  voice— some  forms  of  hysteric  paraplegia  or 
hemiplegia,  more  or  less  complete — chorea  or  tetanus— some  of  the 
curious  paroxysmal  affections  observed  in  hysteria,  and  all  the  varieties 
of  neuralgife  and  simulated  inflammation,  commonly  called  hysteric, 
frequently  arise  from  the  presence  in  the  blood  of  the  impurities 
which  are  the  true  characteristics  of  gout.' 

In  that  list  there  are  names  we  can  now  relegate  outside  the  pale  of 
gout.  At  the  present  time  there  are  still  unrecognised  diseases,  and 
of  some  of  these,  perhaps,  we  may  still  erroneously  refer  the  symptoms 
to  gout ;  but  their  number  cannot  be  great.  Yet  the  concourse  of 
conditions  directly  or  indirectly  referred  to  the  influence  of  gout  is 
truly  remarkable. 

*  This  aspect  was  dwelt  upon  by  Laycock  in  connection  with 
hysteria  : 

'  Of  the  many  cases  related  by  authors  as  anomalous  disease,  by  far 
the  greater  portion  were  connected  with  a  gouty  diathesis,  as  indicated 
both  by  the  formation  of  calculi,  by  the  occurrence  of  regular 
paroxysms  of  gout,  and  by  the  descent  of  the  individual  from  gouty 
ancestors  ;  they  are  cases,  in  fact,  which  would  have  been  better 
understood  and  better  treated  if  they  had  been  termed  "  anomalous 
gout "  ;  but  as  the  subjects  are  young  females,  they  are,  of  course,  set 
down  as  "anomalous  hysteria"'  ('Nervous  Diseases  of  Women,' 
p.  163,  quoted  by  Sir  Spencer  Wells,  loc.  cz'L,  p.  163). 

Since  that  date  the  rise  of  the  pathology  of  the  nervous  system  has 
led  to  the  domain  of  hysteria  being  considerably  broken  up  ;  but  it 
cannot  be  said  that  any  appreciable  share  of  it  has  fallen  to  gout. 
These  lines  are  quoted  as  illustrating  the  unavoidable  fluctuation  in 
the  nosological  position  of  symptoms,  so  long  as  they  lack  a  strict 
pathological  explanation.  We  are  not  exempt  from  the  same  uncer- 
tainties, though  less  and  less  exposed  to  them. 


24      ATTENUATION  AND  FREQUENCY  OF  GOUTINESS 

Granted,  then,  a  large  retinue  of  kindred  states,  we 
must  still  carefully  check  them  as  to  their  absolute 
identity  with  gout.  We  are  still  liable  to  similar  mistakes. 
Although  many  diseases  have  been  identified  and  their 
manifestations  excluded  from  the  gouty  connection,  the 
supply  of  newly-observed  phenomena  awaiting  an  ex- 
planation is  constantly  kept  up  by  the  searching  modern 
methods  of  clinical  study ;  and  immature  gout  may  be  at 
times  erroneously  credited  with  the  causation  of  novel 
symptoms.  In  less  than  forty  years  deductions  may  have 
to  be  made  from  our  present  list  of  so-called  gouty  mani- 
festations, though  probably  not  as  numerous  as  those  we 
now  can  make  in  the  review  of  the  '  gouty '  symptoms 
of  forty  years  ago. 


CHAPTER  V. 

THE  GENERAL  ETIOLOGY  OF  GOUT. 

The  general  aetiology  of  gout  as  regards  heredity,  age, 
sex,  climate,  and  conditions  of  life  is  fairly  well  known. 

At  least  half  the  cases  of  gout  are  inherited.  This  is  about 
the  proportion  worked  out  by  Sir  A.  Garrod.  Scudamore 
found  a  ratio  of  309  to  523,  and  other  observers  a  still 
higher  proportion ;  a  few  only  estimating  it  at  one-third. 

Most  commonly  gout  is  inherited  from  the  father. 
Maternal  gout,  however,  being  less  frequently  of  a  declared 
type,  may  often  have  been  overlooked  in  statistics  ;  this 
might  partly  account  for  the  wide  differences  between  the 
various  estimates.  It  has  long  been  known  that  the  later 
offspring  is  more  liable  than  the  earlier,  and  Mr.  J.  Hut- 
chinson* draws  attention  to  the  fact  that  the  last  born  of 
a  gouty  progeny  are  more  likely  to  develop  the  affection 
early  and  to  suffer  severely. 

Gout  is  undoubtedly  modified  in  transmission.  This  is  a 
natural  consequence  of  the  greater  delicacy  of  the  offspring, 
and  of  the  inheritance  of  gouty  structural  peculiarities  from 
progenitors  whose  own  gout,  if  acquired,  may  have  been 
grafted  on  a  robust  constitution.  Gout,  in  the  weaker 
subject,  could  not  develop  on  the  same  lines  as  in  the 
stronger  one. 

*  '  The  Hereditary  Transmission  of  Gout,'  Medical  Times  and 
Gazette,  May  20,  1876. 


26  THE  GENERAL  ETIOLOGY  OF  GOUT 


Quite  independently  of  this  general  modifying  influence, 
there  are  curious  inconsistencies  and  interruptions  in  the 
hereditary  transmission  of  the  disease.  Some  children 
may  escape  entirely,  while  others  are  attacked ;  or  a 
generation  may  be  spared  by  the  disease,  which  may 
return  in  the  ensuing  one.  Yet  more  strange  are  the 
alternations  frequently  observed  in  the  type  of  the  disease, 
the  arthritic  being  succeeded,  for  one  or  even  two  genera- 
tions, by  the  cutaneous,  the  calculous,  the  nervous,  or 
some  other  visceral  form,  after  which  arthritic  gout  may 
again  occur.  These  observations  open  up  wide  specula- 
tions connected  with  atavism,  a  subject  upon  which  Dr. 
Mortimer  Granville*  has  supplied  some  interesting  re- 
marks. 

Age  is  a  leading  factor.  The  extremes  of  age  are  almost 
exempt ;  early  growth,  which  monopolizes  energy,  and 
senile  decay,  in  which  it  is  almost  extinct,  both  overrule  that 
deviation  of  the  energies  of  nutrition  which  we  consider  to 
be  at  the  root  of  gout.  Gout  begins  at  that  period  of  man- 
hood when  the  first  restlessness  of  youth  is  wearing  off, 
and  gives  way  to  a  greater  appreciation  of  things,  and  to 
a  systematic  enjoyment  of  life.  The  greater  number  are 
attacked  somewhere  before  forty.  Patissierf  found  thirty- 
four  to  be  the  average  age  of  onset  for  inherited  gout,  and 
thirty-eight  for  the  acquired  form.  Not  a  few,  however 
(as  many  as  85  in  a  series  of  515  collated  by  Scudamore), 
begin  their  gouty  history  between  twenty-five  and  thirty  ; 
but  before  twenty  gout  is  exceptional,  and  earlier  cases 
should  be  reckoned  among  the  curiosities  of  gout.  Scuda- 
more mentions  a  case  at  each  of  the  unusually  early  ages 
of  eight,  twelve,  fifteen,  sixteen,  seventeen  ;  and  similar 
instances  are  scattered  through  literature.       It  was  the 

*  '  Notes  and  Conjectures  on  Gout,'  Bailliere,  Tindall  and  Cox. 
f  Quoted  by  Rendu,  loc.  «'/.,  p.  174. 


THE  GENERAL  ETIOLOGY  OF  GOUT  27 

original  observation  of  Hippocrates  that  gout  does  not 
occur  in  the  young  ante  usum  veneris.  Sydenham  says : 
'  Neither  have  I  seen  gouty  minors  or  gouty  children. 
The  most  I  have  observed  is  a  slight  foreshadowing  of  a 
future  attack,  and  this  has  been  in  the  younger  branches 
of  gouty  families.'  At  the  other  extreme  of  life,  the  evolu- 
tion of  gout  at  ninety  in  a  case  mentioned  by  Sir  Dyce 
Duckworth  is  probably  the  most  senile  instance  on  record. 
Garrod  mentions  several  cases  occurring  after  seventy, 
and  Blackmore  also  noted  a  first  attack  at  seventy-eight. 
Scudamore's  list  does  not  mention  any  cases  after  sixty- 
six,  and  only  ten  of  his  cases  occur  after  sixty. 

Sex  plays  an  important  part  in  aetiology.  Gout  is  quite 
exceptional  before  the  menopause,  as  was  laid  down  by 
Hippocrates.  Sydenham  had  also  observed  that  '  gout 
attacks  women  but  rarely,  and  then  chiefly  the  aged  and  the 
masculine.  Where  you  have  symptoms  of  gout  in  slender 
females,  they  are  really  the  symptoms  of  hysteria,  or  else 
of  rheumatism  imperfectly  eliminated.'  We  shall  dwell 
elsewhere  on  the  fact  that  even  after  the  menopause  gouti- 
ness is  much  more  common  in  women  than  declared  gout. 

Social  position  fosters  the  tendency  to  gout  in  the 
measure  of  the  luxuriousness  and  muscular  inactivity 
which  it  brings,  and  of  the  inherited  proclivity  often 
attaching  to  it.  We  are  reminded  of  this  by  Sydenham's 
hues :  '  For  humble  individuals  like  myself,  there  is  one 
poor  comfort,  which  is  this,  viz.,  that  gout,  unHke  any 
other  disease,  kills  more  rich  men  than  poor,  more  wise 
men  than  simple.  Great  kings,  emperors,  generals,  ad- 
mirals, and  philosophers  have  all  died  of  gout.  Hereby 
Nature  shows  her  impartiality,  since  those  whom  she 
favours  in  one  way  she  afflicts  in  another.  A  mixture  of 
good  and  evil  pre-eminently  adapted  to  our  frail  mortality.' 

Climate  and  season  also  markedly  influence  the  prevalence 


28       THE  GENERAL  ETIOLOGY  OF  GOUT 

of  gout.  The  immunity  of  tropical  and  sub  -  tropical 
countries,  and  the  greater  prevalence  of  gout  in  some 
Northern  countries,  harmonize  with  the  common  experi- 
ence that  cold  and  damp  are  among  the  determining 
causes.  Nevertheless,  a  few  remarkable  exceptions  cause 
us  to  doubt  whether  latitude  and  temperature  alone  are 
adequate  to  explain  the  differences  observed.  In  Great 
Britain,  the  North  has  enjoyed  almost  complete  immunity* 
for  centuries  during  which  gout  has  been  prevalent  in 
England.  In  the  northern  section  of  the  European  con- 
tinent, where  winters  are  much  colder  and  more  pro- 
tracted than  in  England,  gout  is  not  prevalent.  In  Italy 
the  South  is  said  to  be  its  special  home ;  and  this  was 
attributed  by  the  late  Professor  Cantani  to  a  direct  in- 
heritance from  the  Greeks  and  the  Romans.  Ancient 
Rome  was  another  striking  exception.  India,  where  gout 
is  unknown  among  the  indigenous  native  tribes,  confers 
immunity  upon  British  residents,  and  also  a  protection 
from  attacks  upon  those  who  have  been  sufferers  from 
gout,  but  only  on  condition  that  their  diet  is  regulated  by 
prudence.  The  Parsees,  who  are,  like  ourselves,  an  im- 
ported race,  suffer  in  a  marked  degree  ;  and  it  is  significant 
that  they  are  large  consumers  of  meat.  Again,  the  con- 
siderable immunity  from  declared  gout  enjoyed  by  Canada 
and  the  United  States,  in  spite  of  their  northern  latitude 
and  cold  winters,  is  not  to  be  explained  as  a  result  of 
latitude  or  temperature.  Rendu,  in  his  able  analysis  of 
the  geographical  distribution  of  gout  {loc.  cit.,  p.  i66), 
suggests  that  behind  the  influence  of  climate  we  probably 
have  to  deal  with  race,  and  especially  with  the  conditions 
of  social  life,  and,  above  all,  with  diet. 

*  Dr.  Hoffman  informs  me  that  this  immunity  no  longer  exists  in 
he  northern  counties  of  England.  During  his  period  of  practice  in 
Northumberland,  he  met  with  many  cases. 


THE  GENERAL  ETIOLOGY  OF  GOUT  29 

The  greater  prevalence  of  gout  in  spring  and  in  autumn 
has  never  been  thoroughly  explained.  It  cannot  be  satis- 
factorily accounted  for  by  the  severity  of  the  cold  or  of 
the  heat.  More  probably  it  is  connected  with  disturbances 
of  the  liver  set  up  by  abrupt  variations  in  the  wind  and 
weather. 

The  exact  share  attributable  to  racial  proclivity  is  difficult 
to  estimate.  The  Anglo-Saxon  and  the  Dutch  stand,  in 
respect  of  gout,  in  a  marked  contrast  to  the  Scotch  and  to 
the  German  or  Scandinavian.  Both  England  and  Holland 
are  remarkable  for  the  humidity  of  their  climate  and  for 
their  liberal  dietary.  On  the  other  hand,  Scotland  and 
Ireland,  the  recognised  homes  of  frugality,  are  no  less 
humid  than  England,  whilst  Germany  enjoys  a  relatively 
dry  climate.  Here,  again,  the  dietetic  factor  seems  to 
predominate  over  the  climatic  and  the  racial.  As  a  fact, 
races  so  far  removed  from  the  regions  of  prevalence  of 
gout  as  even  the  African  tribes  have  furnished  instances 
of  gout  acquired  in  the  individual  after  emigration,  owing 
to  rich  living.  The  Arabs  in  the  palmy  days  of  their 
mediaeval  empire  were  also  addicted  to  gout,  but  are  now 
almost  entirely  exempt. 

The  general  conchision  must  be,  that  no  race  and  no 
climate  can  claim  to  be  absolutely  exempt  from  the  risk 
attaching  to  indulgence  in  luxurious  habits  and  excess  in 
diet,  and  that  the  immunity  enjoyed  by  the  tropical 
countries  is  in  a  large  measure  explained  by  the  activity 
of  cutaneous  excretion,  and,  above  all,  by  the  fact,  tersel}^ 
expressed  by  Rendu,  that  '  these  are  countries  in  which 
we  cannot  survive  unless  we  are  frugal.'  More  potent, 
then,  than  climatic  and  racial  peculiarities  are  the  habits 
of  the  individual. 

Temperament  may,  to  a  certain  extent,  determine  the 
type  of  gout,  but  gout  is  not  the  monopoly  of  any  special 


30  THE  GENERAL  MTIOLOGY  OF  GOUT 

temperament.  According  to  Rendu  {loc.  cit.,  p.  176), 
sthenic  arthritic  gout  occurs  in  the  full-blooded  ;  spare  and 
nervous  subjects  are  liable  to  the  neuralgic,  neurotic,  and 
neuropathic  manifestations,  including  asthma  and  other 
spasmodic  forms  of  visceral  gout;  whilst  bilious  subjects 
would  suffer  from  the  dyspeptic  and  hepatic  ailments,  and 
would  be  specially  predisposed  to  haemorrhoids.  We  have 
it  on  Scudamore's  authority  that  the  gouty  often  present 
a  decided  tendency  to  obesity — according  to  his  tables,  in 
the  proportion  of  126  to  156. 

The  influence  of  diet  and  beverage  is  discussed  in  a 
separate  chapter.  Acquired  gout  is  developed  on  a  mixed 
dietary,  with  liberal  meat  supplies  seasoned  with  alcoholic 
beers  and  wines.  In  inherited  gout  the  same  diet  will 
readily  call  forth  the  manifestations,  but  they  may  also 
break  out  on  a  diet  almost  exclusively  vegetable,  and  in 
the  absence,  or  with  the  utmost  care  in  the  use,  of  alcoholic 
stimulants. 

A  life  oi  physical  inactivity  is  a  potent  factor  in  bringing 
about  general  gout.  Intellectual  labour  and  mental  shock  are 
also  recognised  causes ;  and  it  should  be  noted  that  they 
are  also  operative  in  diabetes,  gravel,  and  biliary  lithiasis. 
'  Sometimes  also  serious  study  and  prolonged  meditation 
have  increased  the  evil.  This  they  have  done  by  diverting 
the  volatile  spirits  from  their  proper  function  of  assimila- 
tion'  (Sydenham).  In  a  word,  all  physical  and  nervous 
depressing  influences  have  a  share  in  predisposing  to  the 
malady. 


II. 
THE  THEORIES  OF  GOUT. 


CHAPTER  VI. 

BRIEF  GENERAL  SKETCH. 

The  multiplicity  of  our  theories  argues  their  relative 
failure.  None  have  covered  the  whole  ground.  Yet  each 
of  them,  being  based  on  pathological  or  clinical  observa- 
tion, contains  some  instalment  of  the  desired  solution. 
Their  agreement  or  conflict  may  help  the  elucidation  of 
various  doubts ;  and,  if  nothing  more,  we  may  learn  from 
them  that  every  attempt  to  identify  gout  with  any  of  its 
organic  developments  has  proved  futile. 

The  early  history  of  pathology  is  made  up  of  successive 
oscillations  between  two  great  theories — the  '  humoral ' 
and  the  'solidist ';  and  in  the  case  of  gout  the  discussion 
has  lasted  almost  to  the  present  day.  It  is  now  obvious 
that  no  pathology  can  be  built  on  so  exclusive  a  basis. 
The  fluids  and  the  solids  of  the  living  body  are  so  closely 
bound  together  that,  until  released  from  their  union  by 
death,  they  are  inseparable,  and  even  disease  is  dependent 
upon  their  association.  However  much  modern  theories 
may  differ,  they  are  all  humoro-solidist. 

One  of  them,  however,  the  nervous  theory  as  it  was 
taught  by  Cullen,  draws  more  closely  than  the  rest 
towards  the  idea  of  solidism. 


BRIEF  GENERAL  SKETCH 


Another  theory  indines  strongly  towards  humoralism, 
of  which  it  is  the  modern  expression  ;  it  assumes  that  the 
blood  is  vitiated  through  the  defect  or  disturbance  of  the 
secretions,  especially  the  hepatic  and  the  digestive  secre- 
tions. This  was  the  view  of  Sydenham ;  and  within  our 
own  time  the  contamination  of  the  blood  has  been  further 
traced  by  Murchison  in  his  studies  on  lithasmia  to  the 
admixture  of  faulty  secretions  from  the  liver  and  digestive 
organs,  and  by  Garrod  to  a  retention  of  uric  acid,  owing 
to  its  defective  elimination  by  the  kidney. 

The  '  Humoral '  and  the  '  Nervous  '  Theories. — In  earlier 
days,  when  the  mysteries  of  nerve  life  and  activity  were 
unrevealed,  and  the  yet  more  elementary  function — that 
of  which  one  of  our  greatest  modern  statesmen  once 
said,  '  Everything  depends  upon  the  circulation  ' — was 
not  dreamt  of  whether  as  regards  the  blood  or  the  lymph 
stream,  the  alimentary  function  was  within  easier  reach, 
and  occupied  a  larger  place  in  the  theories  of  the  day. 

The  fluids  found  in  the  alimentary  canal,  in  the  vascular 
system,  in  the  secreting  and  excreting  glands,  and  in  the 
tissues  themselves,  were  regarded  as  the  agents  of  disease. 
This  was  the  humoral  theory  in  its  crude  and  exclusive 
form  ;  but  a  great  deal  of  it  was  true,  and  has  lasted. 
Indeed,  in  the  latest  theory,  the  primary  humoral  aspect 
of  faulty  nutrition  has  been  worked  in  by  Sir  Dyce  Duck- 
worth with  the  secondary  dystrophic  aspect  based  upon 
disordered  innervation. 

Stahl,  who  in  his  day  played  the  part  of  a  reformer  in 
pathology,  was  the  first  to  refuse  allegiance  to  the  humoral 
doctrine,  of  which  Sydenham  had  been  the  last  great 
representative.  He  endeavoured  to  trace  the  disease  to 
the  disordered  activities  of  the  organism.  Cullen,  adopt- 
ing his  teaching,  carried  it  to  its  ultimate  conclusions. 
He  completely  denied  all  share  to  a  morbific  material. 


BRIEF  GENERAL  SKETCH  33 

and  attributed  the  production  of  gout  to  abnormal 
functions  of  the  nervous  system.  He  may  be  regarded  as 
the  chief  exponent  of  a  purely  nervous  theory.  His  views 
were  too  uncompromising  to  obtain  a  lasting  hold  on 
medical  thought.  Nevertheless,  they  had  done  service  in 
effectually  breaking  through  the  old  tradition,  and  in 
demonstrating  the  fallac}^  of  the  opposite  extreme. 

After  a  period  of  perplexity  and  doubt,  the  gradually 
reasserted  influence  of  Sydenham,  the  discovery  of  the 
presence  of  uric  acid  in  the  gouty  concretions  by  Wol- 
laston,  and  the  increasing  importance  attached  to  it, 
slowly  paved  the  way  for  a  modified  humoral  theory, 
which  almost  identified  the  materia  peccans  with  uric  acid. 

The  exposition  of  these  views  was  the  signal  for  a 
revival  of  the  claims  of  the  nervous  theory,  no  longer, 
however,  in  the  original  vitalist  form,  but  as  a  compromise 
with  and  an  addition  to  the  henceforth  undeniable 
humoral  factor.  The  tendency  in  late  years  to  associate 
a  nervous  influence  with  the  chemical  changes  has  great 
significance  in  connection  with  the  vast  progress  of 
clinical  observation  and  analysis. 

THE  URIC  ACID  THEORY. 

Garrod's  researches  form  the  turning-point  in  the 
history  of  the  pathology  of  gout,  by  substituting  for  pure 
hypotheses  some  definite  facts,  and,  above  all,  a  demon- 
stration of  the  abnormal  presence  of  uric  acid  in  the  blood 
and  in  the  tissues  of  the  gouty.  Since  then  the  uric  acid 
side  of  the  pathology  of  gout  has  claimed  an  increasing 
share  of  attention,  both  in  the  laboratory  and  clinically. 

The  conception  of  a  uric  acid  dyscrasia,  upon  which  the 
modern  views  of  gout  are  so  largely  based,  is  almost  ex- 
clusively humoral.  There  is,  however,  from  the  humoralist 
standpoint,  a  curious  inconsistence  in  the  fact  that  the 

3 


34  THE  URIC  ACID  THEORY 

mischievous  property  is  in  this  case  identified  with  a  solid, 
the  sodium  biurate  crystal.  So  long  as  uric  acid  is  in 
solution  in  the  blood  or  the  juices  no  gouty  trouble  ensues  ; 
but  with  its  precipitation  in  or  about  the  joints,  and  in 
other  situations  as  biurate,  it  becomes  harmful. 

Another  view  more  consonant  with  pure  humoralism 
is  that  taken  by  Dr.  Haig.  Whilst  not  denying  a 
mechanical  power  for  harm  to  uric  acid  in  the  crystalline 
form,  he  insists  on  the  deleterious  action  of  uric  acid  when 
it  happens  to  be  circulating  in  the  soluble  state ;  and  he 
has  described  various  results,  not  in  themselves  gouty,  but 
many  of  them  analogous  to  gouty  phenomena,  as  a  result 
of  this  influence.  The  development  of  Dr.  Haig's  views 
might  be  identified  as  the  toxic  uric  acid  theory  of  gout,  in 
contrast  with  the  other  aspect  of  the  uric  acid  theory,  re- 
lating to  the  crystallized  salts  of  uric  acid,  which  might 
be  identified  as  the  mechanical  uric  acid  theory  of  gout. 

Lastly,  Ebstein  has  combined  the  two  views,  and,  as 
will  be  elsewhere  explained,  has  conceived  a  double  and 
reciprocal  influence — toxic  on  the  one  hand,  mechanical 
on  the  other — between  the  tissues  and  the  biurate.  This 
view  we  may  refer  to  as  the  mechanical  and  toxic  uric  acid 
theory. 

Observations  and  discussions  as  to  the  behaviour  of  uric 
acid  and  of  the  biurate  were  a  comparatively  simple 
matter,  these  substances  presenting  themselves  for  in- 
spection, and  being  accessible  to  chemical  investigation. 
A  much  more  difficult  question,  '  Why  does  the  biurate 
occur  in  the  wrong  place  and  in  abnormal  quantities  ?'  is 
that  to  which  investigators  have  hitherto  failed  to  give 
a  satisfactory  answer.  The  elementary  factors  of  this 
problem  are  wanting,  for  it  is  still  debated  whether  there 
is  an  excess  in  the  production,  or  merely  an  undue  storage 
of  uric  acid.     Overproduction  is  represented   by  Haig's 


THE  URIC  ACID  THEORY  35 

theory  of  faulty  alimentation,  retention  by  Garrod's  views, 
which  have  found  favour  ever  since  their  publication. 
Garrod  does  not  altogether  discard  the  idea  of  overpro- 
duction ;  he  traces  in  the  gout  of  the  wealthy,  free-living 
subject  the  excess  of  uric  acid  to  an  excess  in  the  sup- 
plies ;  but  he  points  to  the  poor  man's  gout  as  probably 
brought  about  by  retention  only.  In  all  cases,  however, 
retention  is  the  determining  factor  of  the  attack. 

The  Theory  of  Renal  Block. — An  excess  of  uric  acid  in 
the  blood,  coinciding  during  the  attack  with  a  diminu- 
tion in  the  urine,  favoured  the  assumption  that  the  uric 
acid  was  hindered  in  its  escape  through  the  normal 
channels  of  excretion.  The  obstacle  to  excretion  was 
further  assumed  to  reside  in  the  kidney ;  but  its  precise 
nature  has  never  been  made  clear.  This  alleged  renal 
block  is  the  more  mysterious  since  commonly  no  morbid 
change  can  be  detected  in  the  kidney,  and  the  renal  in- 
ability to  excrete  uric  acid  whilst  other  substances  are 
excreted  is  neither  absolute  nor  lasting.  Any  defect 
would  have  to  be  regarded  as  functional  rather  than 
organic,  and,  moreover,  most  ephemeral.  In  spite  of 
these  difficulties,  the  theory  of  renal  impermeability  has 
been  very  largely  adopted,  and  is  still  almost  universally 
held  to  be  the  best  available  explanation. 

The  strength  of  Sir  A.  Garrod's  position  had  been  its 
strict  limitation  to  the  province  of  uric  acid.  His  philo- 
sophical reticence  as  to  any  more  remote  element  in  the 
disease  drew  the  attention  of  other  writers  more  definitely 
to  those  pathological  aspects  which  appeared  to  have 
suffered  neglect,  and  called  forth  rejoinders  by  Gairdner, 
Barclay,  and  Parkes.  The  views  expressed  by  them 
possess  great  importance,  but  they  failed  to  make  much 
impression  at  that  time,  for  they  were  merely  inferences 
from  clinical  observation,  and  had  not  then  the  support 


36  THE  URIC  ACID  THEORY 

of  any  physical  method  of  demonstration,  such  as  Sir  A. 
Garrod  was  able  to  put  forward. 

The  thoroughness  of  Garrod's  work  was  such,  that  for 
upwards  of  thirty  years  it  called  for  neither  correction  nor 
addition.  At  last,  within  a  recent  period,  it  has  borne 
further  fruit  :  the  chemistry  of  the  uric  acid  compounds 
has  been  explained  by  Sir  W.  Roberts'  admirable  in- 
vestigations. And,  again,  Horbaczewski  has  led  the  way 
of  discovery  into  the  previously  impenetrable  question  of 
the  derivation  of  uric  acid. 

Meanwhile  purely  clinical  research  had  not  been  at  a 
standstill.  Various  observers  successively  criticised  Sir 
A.  Garrod's  statement  of  the  subject  from  the  standpoint 
of  the  nervous  theory.  The  French  idea  of  diathesis 
throve  on  the  rapid  growth  of  the  new  science  of  neurology 
until  the  nervous  theory  was  fairly  revived,  and  this  is 
again  presented  to  us  by  Sir  Dyce  Duckworth  in  his 
treatise  on  gout,  although  the  uncompromising  position 
of  Cullen,  who  denied  the  existence  of  any  morbific  matter 
in  the  process  of  gout,  is  not  again  taken  up. 

Gout  might  also  be  viewed  as  a  disease  of  faulty  nutrition. 
An  excessive  production  of  uric  acid  in  gout  was  easily 
explained,  so  long  as  it  was  postulated  that  uric  acid  was 
a  mere  stage  in  the  series  of  oxidations  of  which  CO2  and 
urea  were  the  ultimate  products.  For  an  excess  of  uric 
acid  two  conditions  were  held  to  be  requisite :  a  glut  of 
nitrogen,  that  is,  surfeit  of  nitrogenous  supplies,  and  a 
defect  in  oxidation. 

It  has  been  shown  long  ago  by  Lehmann  that  the 
amount  of  uric  acid  and  of  urea  were  increased  by  an 
animal  diet.  On  the  other  hand,  it  was  assumed  that  the 
proportion  between  the  uric  acid  and  the  urea  would  be 
dependent  upon  the  amount  of  exercise,  and  that  exercise 
would    increase   the    proportion    of    urea,    and   diminish 


THE  URIC  ACID  THEORY  37 

that  of  uric  acid.  More  recent  investigations  have  shown 
that  neither  the  alleged  facts  nor  the  arguments  based 
upon  them  are  absolutely  correct. 

Gout  is  not  altogether  a  disease  of  aliiiientation.  It  is 
not  an  intoxication  by  meat  analogous  to  ergotism  pro- 
duced by  diseased  rye.  Human  subjects  may  eat  meat 
largely,  nearly  as  exclusively  as  carnivora,  and  not  have 
the  gout.  It  is  not  the  animal  food  as  such,  but  the  be- 
haviour of  the  living  protoplasm  towards  the  nutritive 
juices,  especially,  though  not  exclusively,  those  derived 
from  animal  food,  which  comes  into  account.  The 
nutritive  intracellular  activities  may  be  exuberant  or  de- 
pressed, or  perhaps  of  the  wrong  kind.  It  is  with  these 
aberrations  that  gout  would  seem  to  be  associated  ;  and 
gout  might  be  regarded  as  a  disease  of  faulty  ntitrition. 

The  most  elaborate  tissues  and  functions  being  the  most 
dependent  upon  a  perfect  nutrition,  the  nervous  system 
must  be  among  the  earliest  to  suffer  under  faulty  nutri- 
tional conditions.  An  instance  of  this  is  seen  in  myx- 
oedema.  In  gout  the  nervous  phenomena  are  well  to  the 
front,  and  many  of  them  are  the  expressions  of  the  nutri- 
tional upset. 

Faulty  innervation  contributes  largely  to  the  list  of 
neuroses  and  functional  visceral  crises.  By  reason  of  the 
leading  position  of  the  nervous  system,  its  disturbances  are 
reflected  to  the  entire  organism.  Its  directing  power  for 
metabolism  may  even  be  turned  into  a  means  for  disturb- 
ing metabolic  processes  in  the  direction  of  the  gouty 
change.  Indeed,  an  incomplete  study  of  the  matter,  in 
which  the  original  error  of  metabolism  was  overlooked, 
might  suggest  the  idea  that  gout  was  primarily  a  disease 
of  the  nervous  system.  It  is  in  that  way  that  the  nerve 
theory  of  gout  has  originated. 

In  conclusion,  we  still  notice  two  great  tendencies  :  the 


38  THE  URIC  ACID  THEORY 

modified  solidist,  in  that  theory  which  Sir  Dyce  Duck- 
worth so  happily  terms  '  the  neuro-humoral  theory ' ;  and 
the  modified  humoral,  in  Garrod's  rejtal  and  uric  acid 
theory.  A  humoral  influence  is  admitted  by  all,  but  the 
positions  of  importance  are  variously  bestowed  upon  the 
nervous  system,  upon  the  disturbed  chemistry  of  the 
organism,  or  upon  its  final  gouty  product,  uric  acid. 

The  foregoing  is  an  incomplete  sketch  of  some  of  the 
ideas  which,  variously  combined  or  associated,  have 
served  to  build  up  the  manifold  theories  of  gout. 

A  brief  review  of  the  theories  themselves  may  be  of 
service.  Although  their  diversity  reflects  the  extent  of 
our  ignorance,  from  each  of  them  something  may  be 
gleaned  as  from  a  keenly  thought-out  interpretation  of 
observed  facts  ;  but  much  more  may  be  gained  from  their 
joint  consideration,  so  far  as  they  can  be  compared. 
Some  of  them  deal  only  with  the  pathology  of  the 
arthritic  phase,  others  mainly  with  the  setiological  factors 
which  lead  up  to  that  phase;  in  a  third  group  the  two 
subjects  are  considered  jointly,  sometimes  with  some 
degree  of  confusion,  and  we  are  left  to  differentiate  between 
them. 


CHAPTER  VII. 
THE  CHEMICAL  THEORIES.* 

GARROD'S  THEORY  OF  URIC  ACID  EXCESS  AND  OF 
RENAL  INADEQUACY. 

Pathology  remains  indebted  to  Sir  A.  Garrodf  for  the 
central  facts  which  have  been  the  starting-point  of  all 
subsequent  investigations,  and  are  the  acknowledged  basis 

*  Sir  W.  Roberts'  investigations  and  opinions  will  be  considered  in 
the  pages  devoted  to  the  Cheniistry  of  Gout. 

t  The  circumstance  that  uric  acid,  discovered  by  Scheele  in  1775 
in  urinary  calculi  and  in  urine,  and  identified  in  gouty  concretions  by 
Wollaston  in  1797,  had  subsequently  been  regarded  by  clinical 
observers  as  the  constant  accompaniment  of  the  disease,  does  not  in 
any  way  detract  from  the  value  of  the  proof  given  by  Sir  A.  Garrod  of 
the  absolute  relation  of  cause  and  effect. 

The  way  in  which  the  presence  of  uric  acid  in  the  blood  was 
demonstrated  is  matter  of  history,  but  we  cannot  refrain  from 
describing  it  in  the  discoverer's  own  words  : 

'  I  have  named  the  process  the  "  uric  acid  thread  experiment,"  and 
it  is  thus  performed  :  Take  from  one  to  two  fluid  drachms  of  the 
serum  of  blood,  and  put  it  into  a  flattened  glass  dish  or  capsule  ; 
those  I  prefer  are  about  three  inches  in  diameter,  and  one-third  of  an 
inch  in  depth,  which  can  be  readily  procured  at  any  glass-house  ;  to 
this  add  ordinary  strong  acetic  acid,  in  the  proportion  of  six  minims 
to  each  fluid  drachm  of  serum,  which  causes  the  evolution  of  a  few 
bubbles  of  gas.  When  the  fluids  are  well  mixed,  introduce  one  or  two 
ultimate  fibres,  about  an  inch  in  length,  from  a  piece  of  unwashed 
huckaback  or  other  linen  fabric,  which  should  be  depressed  by  means 
of  a  small  rod,  as  a  probe  or  point  of  a  pencil.  The  glass  should 
then  be  put  aside  in  a  cool  place,  until  the  serum  is  quite  set  and 
almost  dry  ;  the  mantelpiece  in  a  room  of  the  ordinary  temperature, 


40  GARROD'S  THEORY 

of  all  chemical  theories  on  gout.  Excess  of  uric  acid  in  the 
blood  is  the  immediate  precursor,  and  its  deposition  in  the 
tissues  in  the  shape  of  crystalline  urate  of  sodium  is  the  chief 
feature  of  the  local  manifestations,  of  the  disease. 

The  excess  of  uric  acid,  though  admitted  to  be  partly 
due  to  an  increased  formation,  is  particularly  identified 
by  Garrod  with  an  imperfect  removal  from  the  blood.  At 
this  point  theory  begins. 

Structural  changes  in  the  kidney  are  the  too  frequent, 
if  not  the  ultimately  inevitable  result  of  inveterate  gout. 
At  the  onset  of  the  disease  none  have  hitherto  been  found, 
except  those  sometimes  brought  about  by  some  inde- 
pendent affection.  The  kidneys  being  healthy  in  structure, 
they  might,  nevertheless,  be  at  fault  in  their  function  ;  and 
it  is  this  view  that  Sir  A.  Garrod  has  advocated.  Accord- 
ing to  him,  a  reduced  efficiency  of  the  kidney  in  clearing 
the  blood  of  its  uric  acid  is  the  first  step  that  can  be 
identified  in  the  process  of  disease.* 

or  a  bookcase,  answers  very  well,  the  time  varying  from  thirty-six  to 
sixty  hours,  depending  on  the  warmth  and  dryness  of  the  atmosphere. 

'  Should  uric  acid  be  present  in  the  serum  in  quantities  above  a  cer- 
tain small  amount  noticed  below,  it  will  crystallize,  and  during  its 
crystallization  will  be  attracted  to  the  thread,  and  assume  forms  not 
unlike  that  presented  by  sugar-candy  upon  a  string,  as  shown  in 
Plate  v.,  fig.  5,  a,  b,  c.  When  in  the  dark  field  under  polarized  light 
it  has  an  appearance  represented  in  the  woodcut  (Fig.  6).  To  observe 
this,  the  glass  containing  the  dried  serum  should  be  placed  under  a 
linear  magnifying  power  of  about  fifty  or  sixty,  procured  with  an  inch 
object-glass  and  low  eyepiece,  or  a  single  lens  of  one  sixth  of  an 
inch  focus  answers  perfectly.  The  uric  acid  is  found  in  the  form  of 
rhombs,  the  size  of  the  crystals  varying  with  the  rapidity  with  which 
the  drying  of  the  serum  has  been  effected,  and  the  quantity  of  uric 
acid  in  the  blood.  To  ensure  perfect  success,  several  precautions  are 
necessary'  ('A  Treatise  on  Gout  and  Rheumatic  Gout,'  pp.  86,  Z"], 
third  edition.     London,  1876). 

*  It  is  interesting  to  note  that  Charcot  has  pointed  out  that  in  early 
interstitial  nephritis,  whilst  the  solubility  of  urea  ensures  its  ready 


GARROD'S  THEORY  41 


The  grounds  upon  which  he  bases  this  conclusion  are 
experimental  and  clinical : 

*  The  results  of  these  experiments  on  the  condition  of 
the  blood  and  urine  prove  that  uric  acid  is  not  a  product 
of  the  action  of  the  kidneys,  as  frequently  supposed,  but 
is  merely  excreted  from  the  system  by  these  organs. 
They  also  appear  to  indicate  that  the  excreting  function 
of  the  kidneys  with  regard  to  the  solid  portion  of  the 
urine  is  not  a  simple  one,  but  that  urea  and  uric  acid  are 
separately  eliminated ;  also  that  one  of  these  functions 
may  be  impaired  or  destroyed,  the  other  remaining  entire. 
It  appears  also  probable  that,  as  in  albuminuria,  the  urea- 
excreting  function  being  chiefly  impaired,  we  find  a 
vicarious  discharge  of  urea  in  dropsical  effusions,  so  in 
gout  the  uric-acid-excreting  function  being  defective,  chalk- 
like deposits  are  produced  by  a  similar  vicarious  discharge 
of  urate  of  soda.' 

*  Gout  would  thus  appear,  at  least  partly,  to  depend  on 
a  loss  of  power  (temporary  or  permanent)  in  the  uric- 
acid-excreting  function  of  the  kidneys  ;  the  premonitory 
symptoms,  and  those  also  which  constitute  the  paroxysm, 
arising  from  an  excess  of  this  acid  in  the  blood,  and  the 
effort  to  expel  the  materies  morhi  from  the  system.  Any 
undue  formation  of  this  compound  would  favour  the 
occurrence  of  the  disease,  and  hence  the  connection  be- 
tween gout,  gravel,  and  calculus ;  hence  also  the  influ- 
ence of  high  living,  wine,  porter,  want  of  exercise,  and 
other  like  causes,  in  inducing  it.' 

'  This  hypothesis  also  explains  two  facts,  which  have 
been  regarded  as  militating  against  the  humoral  pathology 

escape,  various  other  substances  fail  to  pass  through  the  kidney.  He 
noticed  that  gouty  urine  did  not  yield  after  administration  of  turpen- 
tine the  characteristic  odour  of  violets  ('  Lemons  sur  les  Maladies  du 
Foie  et  des  Reins,'  p.  320  ;  1877). 


42  GARROD'S  THEORY 

of  the  affection,  namely,  its  hereditary  nature,  and  its  fre- 
quent occurrence  in  low  states  of  the  system  ;  for  we  can 
understand  that  the  peculiarity  of  the  kidney  with  refer- 
ence to  the  excretion  of  uric  acid  may  be  transmitted, 
and  likewise  that  when  the  function  in  question  is  per- 
manently injured,  it  will  not  require  an  excessive  forma- 
tion of  this  acid  to  cause  its  accumulation  in  the  blood ' 
('  Med.  Chir.  Trans.,'  1848 ;  *  Gout  and  Rheumatic  Gout,' 
pp.  272,  273). 

'  My  present  experience  on  the  subject  shows  that  in 
the  earlier  stages  of  acute  gout  the  urine  is  scanty,  and  the 
uric  acid,  measured  by  the  twenty-four  hours'  excretion, 
diminished ;  that  the  acid  is  thrown  out  in  much  larger 
quantities  as  the  disease  is  passing  off,  and  that  then 
amounts  even  above  the  patient's  daily  average  may  be 
excreted,  forming  the  so-called  critical  discharges  ;  that 
after  a  time  the  uric  acid  is  again  lessened,  although  not 
to  the  extent  observed  prior  to  or  at  the  commencement 
of  an  attack'  {loc.  cit.,  p.  133). 

Urea,  the  most  important  of  the  renal  secretions,  was 
found  by  Garrod  not  to  be  markedly  reduced  in  quantity 
in  the  urine. 

Briefly  stated,  Garrod's  theory  rests  on  the  following 
views : 

1.  The  accumulation  of  uric  acid  in  the  blood,  which  is 
a  necessary  antecedent  of  gout,  is  due  to  a  functional 
renal  defect,  which  may  be  inherited  or  acquired. 

2.  The  local  deposition  of  urate  of  sodium,  howsoever 
determined — and  its  aetiology  includes  the  operation  of 
all  those  causes  which  lead  to  a  diminished  alkalinity  of 
the  blood,  and  thus  to  an  easier  precipitation  of  the  uric 
acid,  as  determining  agents  for  the  attack — is  the  specific 
cause  of  the  local  inflammation,  no  other  affection  being 
accompanied  by  a  deposition  of  urate  of  sodium  in  the 
tissues. 


GARROD'S  THEORY  43 

3.  The  local  inflammation  has  a  curative  effect  at  large, 
inasmuch  as  it  seems  to  destroy  the  urate  of  sodium  in  the 
blood  of  the  inflamed  parts. 

Sir  A.  Garrod  gives  a  complete  summary  of  his  opinions 
in  the  following  propositions  :* 

'  First,  in  true  gout,  uric  acid,  in  the  form  of  urate  of 
soda,  is  invariably  present  in  the  blood  in  abnormal 
quantities,  both  prior  to  and  at  the  period  of  the  seizure, 
and  is  essential  to  its  production ;  but  this  acid  may 
occasionally  exist,  at  least  for  a  time,  in  the  circulating 
fluid  without  the  development  of  inflammatory  symptoms, 
as  in  cases  of  lead-poisoning.  Its  mere  presence,  there- 
fore, does  not  explain  the  occurrence  of  the  gouty  paroxysm. 

'  Secondly,  the  investigations  detailed  in  the  chapter 
on  the  "  Morbid  Anatomy  of  Gout  "  prove  incontestably 
that  true  gouty  inflammation  is  always  accompanied  with 
a  deposition  of  urate  of  soda  in  the  inflamed  part. 

'  Thirdly,  the  deposit  is  crystalline  and  interstitial,  and, 
when  once  the  cartilages  and  ligamentous  structures 
become  infiltrated,  remains  for  a  lengthened  time,  often 
throughout  life. 

'  Fourthly,  the  deposited  urate  of  soda  may  be  looked 
upon  as  the  cause,  and  not  the  effect,  of  the  gouty 
inflammation. 

'  Fifthly,  the  inflammation  which  occurs  in  the  gouty 
paroxysm  tends  to  the  destruction  of  the  urate  of  soda 
in  the  blood  of  the  inflamed  part,  and  consequently  of 
the  system  generally. 

'  Sixthly,  the  kidneys  are  implicated  in  gout,  probably 
in  its  early,  and  certainly  in  its  chronic  stages ;  and  the 
renal  affection,  possibly  only  functional  at  first,  subse- 
quently becomes  structural ;  the  urinary  secretion  is  also 
altered  in  composition. 

*  Loc.  a'f.,  pp.  274,  275. 


44  GARROD'S  THEORY 

'  Seventhly,  the  impure  state  of  the  blood,  arising  prin- 
cipally from  the  presence  of  urate  of  soda,  is  the  probable 
cause  of  the  disturbance  which  precedes  the  gouty  seizure, 
and  of  many  of  the  anomalous  symptoms  to  which  sufferers 
from  gout  are  liable. 

*  Eighthly,  the  causes  which  predispose  to  gout,  inde- 
pendently of  those  connected  with  individual  peculiarity, 
are  either  such  as  produce  an  increased  formation  of  uric 
acid  in  the  system,  or  lead  to  its  retention  in  the  blood. 

'  Ninthly,  the  causes  exciting  a  gouty  fit  are  those 
which  induce  a  less  alkaline  condition  of  the  blood  ;  or 
which  greatly  augment,  for  the  time,  the  formation  of  uric 
acid ;  or  such  as  temporarily  check  the  eliminating  power 
of  the  kidneys. 

'  Tenthly,  in  no  disease  but  true  gout  is  there  a  deposi- 
tion of  urate  of  soda  in  the  inflamed  tissues.' 

RALFE'S  THEORY  OF  LESSENED  ALKALINITY  OF  THE 
METABOLISM. 

Diminished  alkalinity  of  the  blood  must  promote  the 
precipitations  of  uric  acid,  even  though  the  production  of 
the  latter  be  not  excessive  or  its  renal  excretion  diminished. 

Defective  elimination  by  the  kidney  has  yet  to  be 
proved.  The  first  step  would  be  an  accumulation  in  the 
blood  of  acids  and  of  acid  salts,  and  associated  with  this  a 
failure  of  the  tissues  to  reduce  the  uric  acid,  as  occurs  in 
health  ;  the  next  step,  a  precipitation  (favoured  by  acidity) 
of  uric  acid,  on  the  slightest  disturbance,  in  tissues  lying 
outside  the  swifter  currents  of  the  circulation. 

Dr.  Ralfe  regards  the  action  on  some  special  nerve- 
centre  of  '  the  predisposing  causes  of  gout '  as  a  probable 
factor  in  the  production  of  the  gouty  attack.  Accumula- 
tion of  uric  acid  in  the  blood,  and  deposition  of  urate  of 
sodium  in  the  tissues,  are  the  results  of  the  latter. 


PFEIFFER'S  THEORY  45 

PFEIFFER'S  THEORY:  THE  GOUTY  ATTACK  DUE  TO 
A  RE-SOLUTION  OF  THE  DEPOSITS. 

Pfeiffer  endeavours  to  explain  gout  and  gravel  on  the 
assumption  that  in  the  '  uric  acid  diathesis '  the  acid  takes 
on  a  less  soluble  form,  is  less  freely  excreted,  and  is  more 
liable  to  be  precipitated  in  a  gradual  and  latent  manner 
into  the  tissues.  So  long  as  nothing  interferes  with  the 
insoluble  state  of  the  deposits,  nothing  will  happen.  Any 
wave  of  increased  alkalinity  passing  over  the  blood  would, 
however,  bring  on  pain,  and  perhaps  a  gouty  attack, 
which  Pfeiffer  explains  by  supposing  that  the  deposits  are 
then  partly  dissolved,  and  that  the  urates  in  solution 
occasion  the  local  irritation.  Thus,  Pfeiffer  assumes  that 
during  the  arthritic  attack  the  insoluble  form  of  uric  acid 
is  reconverted  into  the  soluble  form.  This  theoretical 
view  he  supports  by  his  clinical  observation  of  increased 
pain  after  administration  of  alkalies,  and  of  the  relief  to 
the  pain  afforded  by  acids,  especially  by  salicylic  acid  in 
large  doses."^ 

The  Excretion  of  Uric  Acid  as  influenced  by  Age. — 
Pfeiffer  maintains  that  the  relative  amount  of  uric  acid 

*  Pfeiffer  professes  to  have  obviated  the  pain  usually  produced  by 
subcutaneous  uric  acid  injections  by  means  of  a  previous  course  of 
5  to  8  grammes  of  hydrochloric  acid,  or  of  phosphoric  acid  adminis- 
tered daily.  As  pointed  out  by  Sir  W.  Roberts,  it  is  extremely  difficult 
to  make  much  impression  on  the  reaction  of  the  blood,  additional 
quantities  of  acid  or  alkalies  being  quickly  expelled  by  the  kidney. 
Freudberg  (Virchow's  '  Archiv,'  Bd.  125,  p.  566,  quoted  by  Levison, 
loc.  cit.,  p.  49)  and  others  have  established  this  fact  by  careful  experi- 
ment. Thus,  daily  doses  of  4  to  8  grammes  of  hydrochloric  acid  do 
not  alter  the  reaction  of  the  blood  ;  it  takes  from  10  to  30  grammes  of 
lactic  acid  to  lessen  the  alkalinity  of  the  blood  by  one-fifth  to  one- 
quarter  ;  and  5  to  10  grammes  of  tartaric  acid  to  reduce  it  by  one- 
sixth.  In  the  same  way  sodium  bicarbonate  in  doses  of  5  to  15 
g-rammes,  though  they  sometimes  increase  the  alkalinity  by  one- 
fourth,  at  other  times  may  make  no  difference  whatever  to  the  reaction. 


46  PFEIFFER'S  THEORY 

normally  excreted  bears  a  definite  relation  to  age,  and 
that  it  progressively  diminishes  with  increasing  years. 
Pfeiffer  gives  the  following  amounts  for  lOO  kilos  of 
body-weight,  during  the  successive  decennia  : 


First  decennium             

..     I '280  grammes. 

Second  decennium         

••     i'ii3 

Third  decennium            

..     I -024         „ 

Fourth  decennium          

..     0-965  gramme. 

Fifth  decennium             

..     0-882        „ 

Seventh  decennium 

-     0752        „ 

Ninth  decennium           

••     o*577        „ 

The  Uric  Acid  Filter. — Pfeiffer  has  claimed  for  gouty 
urine  the  curious  peculiarity  that  when  filtered  through 
o*5  gramme  of  pure  uric  acid  it  leaves  its  uric  acid  on  the 
filter.*  The  same  is  observed  in  the  case  of  healthy 
urine,  but  much  more  uric  acid  (2  to  3  grammes)  is  said 
to  be  required  to  ensure  the  result.  Pfeiffer  regards  this 
difference  as  a  confirmation  of  his  view  that  in  the  gouty 
diathesis  the  urates  assume  a  less  soluble  modification 
than  that  which  belongs  to  the  physiological  state  ;  whilst 
during  the  gouty  attack  the  insoluble  variety  passes  again 
into  the  soluble  form. 

Pfeiffer's  alleged  insoluble  modification  of  the  urates  in 
gout  has  been  placed  in  the  light  of  a  superfluous  assump- 
tion by  Sir  W.  Roberts'  investigations  into  the  chemical 
factors  influencing  the  decomposition  of  the  quadriurates. 

EBSTEIN'S  THEORY  OF  THE  DESTRUCTIVE  ACTION  OF 
URATES  ON  TISSUES. 

Ebstein  attributes  the  uric  acid  excess  in  the  blood,  not 
to  any  pre-existing  renal  defect,  though  a  primary  gouty 

*  Athough  this  method  of  testing  for  the  presence  of  the  'gouty 
diathesis '  has  met  with  some  support  at  the  hands  of  Schetehg  and 
Camerer,  its  value  is  called  in  question  by  Ebstein,  Feliziani,  and  Sir 
W.  Roberts.  Sir  W.  Roberts  finds  that  any  urine  may  be  cleared  of 
its  uric  acid  by  repeated  filtration  through  the  uric  acid  filter. 


EBSTEIN'S  THEORY  47 

nephritis  beginning  with  uratic  deposits  and  ending  in 
fibrosis  sometimes  occurs,  but  to  an  abnormal  extension  of 
its  source  of  supply.  Bone-marrow,  cartilage  and  other 
tissues  are  supposed  to  take  on  its  manufacture.  The 
resulting  excess  in  the  blood  may  be  successfully  dealt 
with  by  increased  renal  excretion,  or  even,  perhaps,  by 
chemical  decompositions  occurring  in  the  blood  ;*  but 
events  do  not  always  take  so  favourable  a  turn. 

Any  accidental  check  to  the  free  circulation  of  the  im- 
pure blood  will  produce  all  the  nervous  discomfort  and 
the  various  symptoms  of  the  gouty  state.  Locally,  if 
there  should  be  actual  arrest  of  the  lymph-stream,  the 
concentrated  solution  of  urates  contained  in  the  stagnant 
lymph  will  exert  its  deleterious  action,  and  may  even 
induce  in  the  tissues  with  which  it  is  in  contact  necro- 
biotic  changes.  All  may  yet  be  well,  however,  if  the 
circulation  be  set  going  again  without  too  great  a  delay. 
In  some  such  way  may  be  explained  the  foci  of  beginning 
necrosis  which  Ebstein  professes  to  have  found  in  portions 
of  the  cartilages  of  gouty  joints  which  were  as  yet  free 
from  any  biurate  crystals.  In  those  portions  where 
crystallization  had  occurred,  a  necrotic  surface  was  in- 
variably exposed,  after  dissolving  the  crystalline  deposit, 
and  this  Ebstein  attributes  to  the  solution  of  urates  acting 
as  a  chemical  poison  for  the  tissues. 

As  a  result  of  the  necrotic  process,  the  tissues  alter 
their  alkaline  reaction  of  its  solution  to  an  acid  one.  At 
that  moment  a  precipitation  of  sodium  biurate  takes  place  : 
a  fit  of  the  gout  has  been  started. 

Ebstein's   theory   is   open   to    many  objections.      The 

*  In  this  connection  may  be  mentioned  the  observation  by  Salomon 
(quoted  by  Levison,  /oc.  «/.,  p.  45),  that  he  could  detect  uric  acid  in 
gouty  blood  only  when  quite  fresh  ;  after  allowing  it  to  stand  twenty- 
four  hours  at  a  temperature  of  37°  C,  all  trace  of  it  seemed  to 
vanish. 


48  EB STEIN'S  THEORY 

fundamental  proposition  that  in  gout  uric  acid  is  produced 
in  a  variety  of  tissues  not  normally  concerned  in  its  manu- 
facture is  set  aside  by  Horbaczewski's  demonstration  that 
in  health  uric  acid  is  a  by-product  of  the  metabolism  of 
almost  all  tissues. 

With  an  over-production  of  uric  acid  and  with  healthy 
kidneys  —  conditions  for  which  Ebstein  contends  —  the 
urine  should  contain  an  excess  of  uric  acid,  instead  of  a 
diminished  amount  (Pfeiffer). 

Ebstein's  experiments  in  fowls  and  serpents  cannot  be 
made  to  apply  to  human  pathology,  not  even  those  which 
resulted  in  a  production  of  necrotic  patches  in  the  liver 
and  in  the  heart-wall  after  ligature  of  both  ureters  in 
fowls  ;  and  it  is  also  to  be  noted  that  in  the  kidney  the 
necrotic  process  was  obtainable  only  after  subcutaneous 
injections  of  potassium  chromate.  As  pointed  out  by 
Levison,  experimental  ligature  or  destruction  of  both 
kidneys  must  set  up  a  uraemia  rather  than  anything  com- 
parable to  gout. 

Lastly,  the  alleged  strong  toxic  property  of  solutions  of 
the  urates  has  not  been  confirmed  by  other  observers. 
Pfeiffer's  experiments*  show  that  solutions  of  urates  of  a 
concentration  such  as  may  occur  in  the  living  body  are 
quite  unable  when  injected  into  the  tissues  to  set  up 
necrotic  changes,  though  they  may  produce  pains  and 
irritation.  Solutions  of  pure  uric  acid  act  as  violent 
irritants,  but  they  are  not  in  question. 

*  Quoted  by  Levison,  loc.  «/.,  p.  48. 


CHAPTER  VIII. 
THE  MODIFIED  CHEMICAL  THEORIES. 

THE    THEORIES    OF  HEPATIC  INADEQUACY— MURCHI- 
SON'S  AND  LATHAM'S  VIEWS. 

The  intimate  connection  existing  between  gout  and 
hepatic  derangement  has  been  recognised  by  most  patho- 
logists, but  it  has  received  special  attention  at  the  hands 
of  Murchison,  and  more  recently  of  Professor  Latham, 
and  to  their  ideas  a  brief  reference  must  be  made. 

Murchison,  whose  views  on  lithsemia  in  connection 
with  various  diseases  are  too  well  known  to  need  com- 
ment, saw  in  gout,  as  in  diabetes,  a  special  variety  of 
functional  derangement  of  the  liver  ;  at  the  same  time  he 
admitted  renal  inadequacy,  especially  in  the  later  stages 
of  gout,  and  an  accumulation  of  uric  acid  in  the  blood,  as 
associated  factors  in  the  disease. 

Murchison's  pathological  and  clinical  researches  have 
gone  far  to  confirm  the  experimental  evidence  supplied  by 
Claude  Bernard  and  subsequent  physiologists  in  favour  of 
the  metabolism  of  the  albuminous  supplies  within  the 
liver,  with  the  direct  production  of  urea,  and  probably 
with  uric  acid  as  a  by-product. 

Professor  Latham*  has  elaborated  a  clinical  theory 
which  defines  more  closely  the  manner  in  which  a  failure 

*  Cf.  'On  the  Formation  of  Uric  Acid  in  Animals,'  1884,  and 
Croonian  Lectures  on  Rheumatism,  Gout  and  Diabetes,  1886. 

4 


50  LATHAM'S  VIEWS 

of  the  hepatic  function  may  lead  to  an  abnormal  pro- 
duction of  uric  acid. 

If  the  glycocine  brought  back  to  the  liver  by  the  portal 
vein,  with  other  reabsorbed  constituents  of  bile,  instead  of 
being  transformed,  as  Professor  Latham  considers  that  it 
should  be,  into  urea,  should  remain  unaltered,  whilst 
other  bodies,  such  as  leucine  and  tyrosine,  undergo  the 
normal  conversion  into  urea,  various  combinations  may 
eventually  arise  between  the  glycocine  and  the  urea.  The 
soluble  compound  known  as  hydantoin  being  formed  in 
this  way  and  carried  to  the  kidney,  and  combining  with 
some  of  the  urea  constantly  present  in  that  organ,  would 
be  transformed  into  ammonium  urate,  which  would  be 
partly  excreted  and  partly  reabsorbed  into  the  blood. 
The  substitution  of  a  molecule  of  the  sodium  abundantly 
contained  in  the  serum  for  a  molecule  of  ammonium  would 
finally  give  rise  to  sodium  biurate,  and  thus  supply  the 
material  for  the  gouty  deposit.  Professor  Latham's 
theory  is  in  harmony  with  the  fact  that  the  absence  of 
uric  acid  from  the  urine  of  herbivora  coincides  in  them 
with  the  absence  of  glycocine  from  the  bile. 

The  non-conversion  of  glycocine  into  urea,  which  would 
be  the  central  fact  in  the  production  of  gout,  finds  a 
parallel  in  diabetes,  where  glucose  likewise  fails  to  be 
further  elaborated.  Both  conditions  would  have  their 
explanation  in  a  disturbance  and  a  partial  suspension  of 
the  normal  metabolism  of  the  liver. 

In  the  case  of  gout,  the  partial  paralysis  of  the  hepatic 
function  would  be  probably  due  to  the  excessive  stimulus 
of  food  in  the  absence  of  sufficient  exercise,  and  might  be 
compared  to  the  paralysis  of  the  submaxillary  gland 
brought  about  by  atropine. 

In  addition  to  purely  chemical  irregularities  connected 
with   the   liver.   Professor   Latham  looks  to  the  nervous 


LATHAM'S  VIEWS  51 

system  for  the  mechanism  which  brings  about  the  attacks 
and  the  inherited  Habihty  to  them,  and  also  determines  their 
locahzation.  He  ascribes  a  leading  share  in  the  pathogeny 
of  the  disease  to  the  central  nervous  system,  without 
specifying  the  locality  of  the  suspected  change.  Whether 
it  be  situated  in  the  medulla  oblongata  or  in  the  spinal 
cord,  it  might  be  either  acquired  or  inherited,  and  would 
explain  in  the  individual  the  existence  of  a  predisposition 
to  gout. 

Latham  suggests  that  if  the  hepatic  disturbance  be 
assumed  to  have  its  determining  cause  in  some  nervous 
weakness  of  the  medulla  oblongata  within  the  district  of 
the  origin  of  the  vagus,  the  weakness  might  also  explain 
the  morbid  reactions  induced  by  an  excess  of  uric  acid  in 
the  blood  within  the  area  of  distribution  of  that  nerve, 
viz.,  the  gastric,  respiratory,  and  cardiac  troubles  so  com- 
monly observed  in  the  gouty ;  whilst  the  affection  of  the 
same  centre  (if  concerned  in  the  trophic  innervation  of  the 
joints),  or  of  some  other,  perhaps  spinal,  centre  presiding 
over  the  nutrition  of  articulations,  might  be  an  active 
determining  factor  of  the  local  processes  in  the  joints. 


DR.  HAIG'S  THEORY  OF  URIC  ACID  AND  EXCESSIVE 
VASCULAR  TENSION. 

Dr.  Haig's  views  stand  alone  in  their  originality  and 
unhesitating  boldness. 

As  in  Garrod's  theory,  what  may  have  preceded  uric 
acid  is  not  under  discussion.  Uric  acid  is  made  our 
starting-point  and  our  beginning,  and  if  we  are  not  over- 
anxious as  to  the  stability  of  this  mid-air  foundation, 
everything  is  evolved  smoothly  from  it  on  the  lines  of 
the  theory.  The  central  facts  assumed  by  Haig  are  : 
(i)  That  uric  acid  is  toxic  in  the  soluble  form,  in  which 


52  HAIG'S  THEORY 


it  circulates  in  the  blood ;  and  (2)  that  it  is  mechanically 
irritating  when  deposited  in  the  joints. 

The  stress  of  the  toxic  effects  falls  largely  on  the 
vascular  system  and  on  the  vaso-motor  function ;  but 
the  consequences  are  varied.  The  range  of  the  dele- 
terious effects  is  not  even  narrowed  down  to  the  gouty 
complex.  All  the  possible  results  of  peripheral  vaso- 
constriction, and  of  heightened  vascular  tension,  are 
capable  of  being  referred  to  uric  acid  as  a  cause.  The 
morbid  results  of  an  excess  of  uric  acid  thus  constitute  a 
considerable  group,  that  of  the  '  uric  acid  diseases,'  of 
which  gout  is  merely  one  member. 

Another  original  view  is  that  taken  of  the  pathology 
of  rheumatism.  Rheumatism  is  included  in  the  '  uric 
acid  diseases.' 

'  In  place  of  rheumatism  and  gout  I  see  but  one  dis- 
ease, an  arthritic  irritation  due  to  the  presence  of  urates, 
which  under  some  circumstances  will  be  limited  to  one 
joint  (gout),  or  affect  several  joints  contemporaneously  or 
in  succession,  and  the  heart  also  (rheumatism).'* 

Haig  undertakes  to  produce  an  arthritis  clinically  indis- 
tinguishable from  gout  or  rheumatism  in  one  perfectly 
healthy.  '  All  that  is  necessary  is  to  get  a  little  uric 
acid  into  the  blood,  and  when  one  can  see  from  the  slow 
pulse,  scanty  urine,  and  more  or  less  headache  and  mental 
depression,  that  it  is  actually  present  there,  one  must 
administer,  as  quickly  as  possible,  some  acid  or  other 
drug  which  interferes  with  the  solubility  of  uric  acid  and 
drives  it  out  of  the  blood  into  the  tissues.'  Some  working 
of  the  joint,  or  the  application  of  some  irritation,  will  also 
be  necessary. 

The  normal  proportion  between  the  uric  acid  and  the 

*  Alexander  Haig,  M.D.,  F.R.C.P.,  '  Uric  Acid  as  a  Factor  in  the 
Causation  of  Disease,'  etc.     Second  edition,  1894,  p.  83. 


HAIG'S  THEORY  53 


urea  excreted  is  assumed  by  Haig  to  be  constant  at 
1-33  or  1-35,  and  its  pathological  variations  are  studied 
elaborately. 

The  quantity  of  uric  acid  in  the  blood*'  varies  much; 
except  perhaps  in  pneumonia  the  blood  always  contains 
less  than  the  liver  or  the  spleen,  which,  of  all  the  organs, 
contain  most,  the  kidneys  containing  less,  and  the  muscles 
least. 

The  joints  are  also  recognised  among  the  structures  in 
which  uric  acid  is  stored.  The  shooting  and  pricking 
pains  in  the  joints  after  a  dose  of  acid  are  held  by  Haig 
to  be  due  to  the  uric  acid  driven  into  them  out  of  the 
blood. 

Among  the  local  factors  of  gout,  Haigf  refers  to  old 
joints  as  probably  being  less  vascular  and  less  alkaline 
than  young  joints,  besides  being  more  exposed  to  the 
influence  of  cold.J 

The  arguments  adduced  in  support  of  the  toxic  effects 
are  singularly  ingenious,  but  they  do  not  include  any 
attempt  to  explain  the  derivation  of  uric  acid,  otherwise 
than  by  ingestion ;  nor  the  mechanism  of  its  operation  in 
the  production  of  gout  ;  nor  why  the  accumulations  of 
uric  acid  from  the  habitual  and  great  over-indulgence  in 
animal  food  should,  in  many  cases,  remain  absolutely 
unproductive  of  any  tendency  to  gout. 

The  main  source  of  uric  acid  is  assumed  to  be  the 
amount  actually  contained  in  the  food,  or  that  arising 
from  its  nitrogenous  elements.  An  animal  diet  having 
for  its  consequences  the  accumulation  of  large  quantities 
of  uric  acid,  which,  in  the  various  situations  in  the  body, 
Haig  estimates  at  an  aggregate  store  of  some  350  to  400 

*  Haig,  loc.  cit.,  p.  73.  f  Loc.  cit.,  p.  313. 

X  Discussion  on  salicylates  and  rheumatism.  '  Proceedings  of  the 
Royal  Medical  and  Chirurgical  Society,'  April,  1890,  p.  109. 


54  HAIG'S  THEORY 


grains  per  annum,  practical  conclusions  are  drawn  in 
favour  of  vegetarianism. 

The  behaviour  of  the  ingested  uric  acid  is  described  in 
the  following  words : 

'  Uric  acid,  when  taken  by  the  mouth,  passes  into  the 
blood,  and,  when  the  conditions  in  that  fluid  are  favour- 
able to  its  solubility,  remains  there  till  it  is  excreted  in 
the  urine ;  that  it  is  not  to  any  appreciable  extent  con- 
verted (as  was  supposed)  into  urea  ;  that  the  rise  of  urea 
which  these  substances  produce  is  secondary  to  the  rise 
of  acidity,  which  they  also  produce ;  and  that  other  acids 
which  introduce  no  nitrogen  into  the  body  produce 
similar  rise  in  the  excretion  of  urea.' 

Any  causes,  such  as  dyspepsia,  producing  a  fall  in  the 
acidity,  will  produce  uricacidsemia.  When  digestion  im- 
proves, acidity  occurs,  and  drives  the  uric  acid  into  the 
joints. 

It  is  to  be  noted  that  the  gouty  attack  occurs  at  night, 
during  the  acid  tide. 

In  the  blood*  according  to  Haig  and  others,  excess  of 
uric  acid  occurs  in  connection  with  deficient  oxidation. 
He  refers  to  Dr.  E.  Peiper's  observation  that  the  alkalinity 
of  the  blood  is  diminished  in  all  fevers,  except  when  these 
are  complicated  with  dyspnoea  or  cyanosis.  This  view  is 
practically  equivalent  to  that  of  Haig,  who  follows  up  the 
causation  of  the  excess,  beyond  a  deficient  oxidation,  to 
a  consequent  deficient  formation  of  acid. 

Perhaps  the  most  striking  feature  of  originality  is  that 
those  metabolic  irregularities  in  which  others  have  looked 
for  the  source  and  origin  of  uric  acid  are  attributed  by 
Haig  to  the  action  of  uric  acid  itself.  As  an  instance  of 
the  influence  of  uric  acid  on  the  general  metabolism,  Haigf 
points  out  that  an  excess  of  uric  acid  in  the  blood  pro- 
*  Haig,  /oc.  cit.,  p.  60.  f  Loc.  cit.,  p.  85. 


HAIG'S  THEORY  55 


duces  a  diminution  of  the  capillary  circulation,  and  there- 
fore a  general  slackening  of  metabolism,  and  a  lessened 
formation  of  urea,  and  of  acids  and  acid  salts  which  usually 
keep  pace  with  urea.  The  increasing  alkalinity  of  the  blood 
induces  more  and  more  marked  uricacidsemia.  But  if  a 
drug  be  given  which  clears  the  blood  of  uric  acid,  the 
process  may  be  quickly  and  completely  reversed  :  '  up  goes 
the  formation  of  urea  and  of  acids,  a  steady  and  pro- 
gressive upward  metabolism  is  started,  and  the  blood  is 
kept  clear  of  uric  acid.'  This  is  the  answer  to  the  ques- 
tion :  Why  does  a  very  minute  dose  of  a  nitrate,  a  few 
grains  of  a  sulphate,  or  a  small  portion  of  a  grain  of 
calomel,  relax  the  arterioles  all  over  the  body,  and  cure 
headache  or  mental  depression  ? 

During  the  early  days  of  a  fever^  metabolism,  being 
very  active,  diminishes  the  alkalinity  of  the  blood ;  uric 
acid  being  removed  from  the  blood,  pains  are  apt  to  be 
felt  in  the  joints  and  elsewhere ;  but  later  on  metabolism 
languishes,  alkalinity  of  the  blood  rises,  and  with  the 
return  of  uric  acid,  pulse  tension  is  apt  to  rise,  and,  as  a 
fact,  dicrotism  towards  the  termination  of  the  fever  may 
cease  to  be  observed. 

Fever  lessens  the  sugar  passed  by  diabetic  patients, 
because,  the  blood  being  cleared  of  uric  acid,  the  arterioles 
are  relaxed  and  metabolism  is  quickened. 

The  effect  of  a  surgical  operation  t  on  the  metabolism 
is  practically  the  same  as  that  of  a  fever.  The  case  of  a 
woman  is  adduced  who  was  under  observation  for  one  or 
two  days  before,  and  one  or  two  after,  abdominal  section. 
After  the  operation  the  amount  of  urea  rose  to  two  or 
three  times  the  normal  amount.  This  Dr.  Haig  regarded 
as  the  result  of  the  very  active  metabolism  locally  induced 
by  the  operation,  the  patient  being  placed  on  a  highly 
*  Haig,  loc.  «■/.,  p.  295.  f  lii'd. 


S6  HAIG'S  THEORY 


nitrogenous  diet  at  the  expense  of  her  tissues.  The 
acidity  rising  with  urea,  it  was  thus  argued  that  the 
surgical  operation  had  the  effect  of  clearing  the  urates 
out  of  the  blood,  of  relaxing  the  arterioles,  and  of  further 
increasing  the  metabolism.* 

Haig  disbelieves  in  inherited  weakness,  innate  delicacy, 
or  transmitted  neurosis,  in  connection  with  uric  acid  dis- 
eases, and  regards  as  the  chief  factors  in  their  causation 
improper  food,  impure  blood,   and  consequent  increased 

*  In  the  paroxysmal  form  of  anainia  Haig  points  to  an  increased 
coagulability  of  the  blood,  and  refers  it  to  uric  acid  {Joe.  at,  p.  254). 

Oxalate  of  lime  is  present  in  the  urine  in  that  disease.  Dr.  Brunton 
has  reminded  us  {Brit.  Med.  Journ.,  vol.  i.,  1885,  p.  167)  that  con- 
centrated urates  in  presence  of  sulphuretted  hydrogen  generate  oxalic 
acid.  The  sulphuretted  hydrogen  probably  is  supplied  from  cabbage, 
and  similar  vegetables  rich  in  sulphur,  in  the  intestinal  canal. 

The  excessive  intestinal  putrefaction  noted  in  epilepsy  by  Herter 
and  Smith  {New  York  Med.  Journ.,  August  and  September,  1892)  is 
explained  in  the  same  way  as  in  the  paroxysmal  and  in  the  pernicious 
forms  of  ansemia,  being  produced  by  uricacidsemia,  general  arteriolar 
contraction,  excess  of  uric  acid,  and  therefore  some  destruction  of 
blood,  whilst  the  contracted  arterioles  suspend  gastro-intestinal  diges- 
tion {of.  Dr.  A.  E.  Garrod,  '  Royal  Medical  and  Chirurgical  Societ^s 
Transactions,'  vol.  Ixxv. :  'The  Anaemia  of  Rheumatism,'  etc). 

Haig  {loc.  czt..,  p.  249)  also  draws  attention  to  the  active  metabolism 
of  young  girls  at  the  age  of  thirteen  ;  they  about  that  time  increase 
by  some  10  to  11  lb.  in  weight  in  the  course  of  a  year  (at  seventeen 
or  eighteen  the  increase  is  only  about  2  lb.).  The  result  of  this 
activity  is  considerable  acidity  of  the  urine  and  low  alkalinity  of  the 
blood,  leading  to  a  storage  of  uric  acid  in  the  body,  in  the  Hver,  spleen, 
and  probably  other  fibrous  tissues. 

The  latter  is  further  increased,  doubtless,  where  there  exists  a 
tendency  to  rheumatism.  At  a  later  period,  as  nutrition  falls,  alkalinity 
rises,  uricacidaemia  supervenes,  with  contracted  arterioles,  slow  tense 
pulse,  headache,  etc. 

Menstruation  still  further  lowers  metaboHsm,  and  tends  to  upset  the 
digestion. 

'  Stimulation  breeds  stimulation  ;  for  if  we  clear  the  blood  of  uric 
acid  for  a  few  hours,  metabolism  will  go  ahead,  and  keep  the  blood 
clear.' 


HAIG'S  THEORY  57 


blood-pressure.  One  factor  may,  however,  be  inherited, 
viz.,  '  a  slight  variation  in  the  size  and  distribution  of  the 
arteries  at  the  base  of  the  brain,  rendering  the  intracranial 
circulation  especially  liable  to  be  affected  by  unduly  high 
blood-pressure.' 

In  conclusion,  gout,  according  to  Dr.  Haig,  would  be 
in  the  strictest  sense  a  '  uric  acid  disease,'  its  local  pheno- 
mena being  merely  the  result  of  a  deposition  of  urates 
into  the  joints,  and  its  constitutional  phenomena  being 
among  the  many  results  which  he  traces  to  their  excess  in 
the  juices. 


CHAPTER  IX. 

THE  HISTOGENOUS  THEORIES,  OR  THEORIES 
OF  A  PRIMARY  PRE-URATIC  TISSUE 
CHANGE. 

The  Nature  of  the  Localizing  Influence.  —  Long  before 
Scudamore,  Van  Swieten  had  called  attention  to  the 
special  liability  of  the  foot  to  various  accidental  lesions 
which  may  act  as  localizing  factors.  Sir  A.  Garrod*  him- 
self dwells  on  the  influence  of  local  mischief  in  causing 
gout  to  appear  in  the  injured  parts.  Many  others  have 
also  thought  and  spoken  of  the  link  which  must  exist  be- 
tween the  structural  and  the  chemical  pathology  of  gout, 
though  none  have  succeeded  in  explaining  wherein  it  con- 
sists. It  was  obvious  from  the  first  that  the  uric  acid 
theory  was  itself  in  need  of  further  explanation.  Among 
recent  theories  none  therefore  deserve  greater  attention 
than  those  which  seek  to  define  strictly  the  connection 
between  tissues  and  juices  and  their  mutual  behaviour. 

Gairdner  had  expressed  the  view  that  the  changes  in 
the  urine  and  the  increase  in  uric  acid  in  the  blood  de- 
scribed by  Garrod  were  rather  a  consequence  of  gout  than 
its  cause,  and  had  suggested  the  probable  existence  of 
some  preliminary  nervous  factor.  The  same  agency  had 
also  been  admitted  by  Laycock,  who  taught  that  gout  is 
not  of  necessity  always  articular,  or  even  always  com- 
*  Loc.  at.,  p.  7. 


THEORIES  OF  PARKES  AND  OF  BARCLAY  59 

bined  with  joint  trouble ;  but  a  more  definite  advance 
towards  the  elucidation  of  the  uric  acid  problem,  which 
has  culminated  in  late  researches  and  discoveries,  was 
foreshadowed  in  his  suggestion  that  a  production  of  uric 
acid  in  the  tissues  rather  than  in  the  blood  was  charac- 
teristic of  gout.  The  same  idea  was  subsequently  ex- 
pressed, though  still  in  a  general  way,  by  Parkes  and  by 
Barclay. 

THEORIES  OF  PARKES  AND  OF  BARCLAY  — A  PRIMARY 

ALTERATION  IN  THE  METABOLISM  OF  THE 

BLOOD,  OR  OF  THE  TISSUES. 

Parkes,*  whilst  disinclined  to  admit  a  primary  inade- 
quacy of  the  kidney,  believed  nevertheless  that  uric  acid 
was  not  only  produced  in  excess,  but  unduly  delayed  in 
the  system.  Holding  the  kidney  responsible  for  the  re- 
tention of  uric  acid,  he  identified  the  retarding  influence 
with  '  important  antecedent  aberrations  in  metamorphosis 
in  the  blood  or  in  the  tissues,  the  abnormal  products  of 
which  might  be  capable  of  holding  back  uric  acid  and 
other  substances,  such  as  phosphoric  acid.' 

Barclayf  recognised  the  check  to  the  renal  elimination 
of  uric  acid  described  by  Sir  A.  Garrod.  The  kidney  at 
this  stage  was  not,  however,  to  be  considered  a  perfectly 
healthy  organ,  but  as  suffering  together  with  other  organs 
under  the  influence  of  a  primary  change  in  the  blood 
corpuscles,  directly  due  to  the  continuance  of  a  faulty 
diet,  till  cell  after  cell  became  affected  and  the  gouty  state 
induced.  The  retention  of  uric  acid  was  to  be  regarded 
'  as  a  symptom,  a  consequence  of  the  attack  of  gout,  and 
not  as  its  cause.'      The  efficacy  of  colchicum,  and   the 

*  Parkes,  'On  Urine,'  p.  298  ;  London,  i860. 

t  Barclay, '  On  Gout  and  Rheumation  in  Relation  to  Disease  of  the 
Heart ;'  London,  1866. 


6o  ORD'S  THEORY 


relative  failure  of  alkalies,  were  for  Barclay  arguments  in 
favour  of  this  theory. 

Barclay's  selection  of  the  red-blood  cell  as  likely  to  be 
specially  concerned  in  the  evolution  of  gout  possesses 
interest  in  connection  with  more  recent  theories  which 
throw  analogous  suspicions  on  the  leucocyte.  His  views 
and  those  of  Parkes  were  important  steps  towards  the 
fundamental  principle  subsequently  enunciated  by  Ord 
and,  at  a  later  date,  by  Ebstein,  that  the  tissues  take  an 
active  share  in  determining  the  deposition  of  uric  acid. 

THEORIES  OF  ORD  AND  OF  EBSTEIN— ANTECEDENT 

STRUCTURAL  CHANGES  CONNECTED  WITH 

THE  CHEMICAL  CHANGES. 

Dr.  Ord's*  theory  is  comprehensive,  and  recognises  the 
part  played  by  the  nervous  system,  as  well  as  that  which 
belongs  to  the  tissues.  He  seeks  the  cause  of  the  primary 
deposition  of  uric  acid  in  some  essential  defect,  inherited 
or  acquired,  in  the  fibroid  tissues.  From  this  original 
deposit  an  overflow  takes  place  into  the  blood,  ultimately 
leading  to  the  invasion  of  the  cartilages  and  of  other 
tissues.  Dr.  Ord  also  believes  in  the  influence  of  nervous 
reflexes  in  causing  a  propagation  of  the  morbid  process  to 
distant  parts.  Not  only  is  this  extension  promoted  in  a 
reflex  way,  but  a  transference  of  the  disease  to  distant 
sites  by  direct  nervous  agency  is  traced  in  the  mode  of 
production  of  the  acute  attacks. 

Gout  may  be  regarded  as  a  disease  of  degenerations,  both 
general  and  local.  The  local  tissue  degeneracies  supply 
a  basis  for  the  uratic  deposits,  and  the  general  degenera- 
tive changes  multiply  the  sites  exposed  to  an  infiltration 
from  the  contaminated  blood ;  whilst  reflex  mechanisms 

*  '  St.  Thomas's  Hospital  Reports,'  New  Series,  vol.  iii.,  p.  237, 
1872  ;  and  Medical  Times  and  Gazette,  vol.  i.,  p.  233  ;  1874. 


ORD'S  THEORY  6i 


step  in  as  additional  determining  agents.  It  is  further 
pointed  out  that  the  local  acute  inflammation  is  not  of 
necessity  specific  in  every  instance,  i.e.,  due  to  the  irrita- 
tion of  the  degenerating  tissues  by  the  crystalline  deposits, 
but  that  it  may  be  set  up  at  times  by  other  exciting 
causes. 

Dr.  Ord's  conclusions  are  these  : 

1.  Gout  is  a  mode  of  decay  of  the  whole  system, 
marked  by  the  deposit  of  urate  of  soda  in  and  about  joints, 
and  by  local  inflammation  of  a  particular  kind. 

2.  The  deposit  of  the  urate  is  a  result  of  local  or  general 
disintegration,  and  is  not  to  be  regarded  as  a  means  of 
eliminating  waste  from  the  blood. 

3.  The  local  inflammations  do  not  necessarily  depend 
upon  the  deposit  of  urate,  and  the  deposit  is  not  a  conse- 
quence of  inflammation  ;  at  the  same  time,  it  is  probable 
that  excess  of  urate  in  the  blood  produces  irritation  of 
tissues. 

4.  The  local  inflammation  is  peculiar  in  respect  of  the 
ease  with  which  it  is  produced,  of  the  pain  by  which  it  is 
attended,  and  of  the  products,  which  are  chemical  rather 
than  structural ;  chemical  substances  of  low  molecule, 
tending  to  crystallize  or  to  be  dissolved,  being  formed  in 
the  part,  instead  of  substances  of  high  molecule  tending 
to  be  organized.  Interstitial  subcrystalline  deposit  is 
common,  suppuration  rare,  in  gout. 

5.  The  local  inflammations  are  set  going  by  local  ex- 
citing causes. 

6.  The  local  degenerations  and  inflammations  tend  to 
infect  the  rest  of  the  system  through  the  blood,  and  to  set 
up  similar  reactions  elsewhere  through  reflex  nerve  action. 

W.  Ebstein*  also  admits  that  gout  is  based  upon  local 

*  Ebstein,] '  Die  Natur  und  Behandlung  der  Gicht ;'  Wiesbaden, 
1882. 


62  EBSTEIN'S  THEORY 

degenerative  changes,  but  he  regards  them  as  produced 
by  a  destructive  action  of  the  concentrated  solution  of 
uric  acid  contained  in  the  juices.  The  prime  factor  is  the 
faulty  metabolism,  induced  in  some  unexplained  way  in 
the  muscles  and  in  the  marrow  of  gouty  persons.  Im- 
pregnation with  soluble  neutral  urate  and  toxic  degenera- 
tion and  necrosis  are  the  early  changes  occurring  in  those 
parts  which  subsequently  suffer  infiltration  with  the 
crystals  of  sodium  biurate,  crystallization  being  itself 
brought  about  by  the  acidity  of  the  necrotic  tissue.  The 
reactions  of  surrounding  parts  to  this  necrotic  and  irrita- 
tive process  constitute  gouty  inflammation.  Crystalliza- 
tion of  the  deposit  is  thus  a  secondary  event,  occasioned 
by  the  conversion  of  the  neutral  into  the  acid  urate  under 
the  influence  of  an  acid  which  he  supposes  to  be  generated 
in  the  necrotic  areas.* 

Ebstein  has  endeavoured  to  prove  by  intracorneal  in- 
jections of  a  saturated  solution  of  uric  acid  in  5  per  cent, 
sodium  phosphate  solution  that  irritating  properties  belong 
to  uric  acid  and  its  compounds.  Sir  W.  Roberts  points 
out  that  the  abundant  and  voluminous  gelatinous  urate 
which  would  soon  separate  from  the  solution  in  question 
would  not  fail  to  irritate  the  cornea,  owing  to  the  extent 
of  the  obstruction  it  would  occasion.  The  comparative 
intracorneal  injections  with  pulverized  uric  acid  and  with 
magnesia  suspended  in  water  are  also  misleading,  owing 
to  the  opposite  behaviour  of  the  two  substances  in  contact 
with  the  alkaline  juices  of  the  cornea. 

*  The  observations  of  Sir  A.  Garrod,  of  Cornil,  of  Ranvier,  of  Sir 
Dyce  Duckworth,  and  of  others,  show  that  necrosis  is  not  a  necessary 
preHminary.  The  needles  of  crystalline  urate  will,  according  to  Sir 
Dyce  Duckworth,  push  their  way  without  any  respect  for  the  compo- 
nent elements  of  the  tissue,  as  if  it  were  an  indifferent  or  homogeneous 
medium  ;  and  it  is  more  natural  to  regard  the  destructive  changes 
as  secondary  to  the  pressure  effects  and  inflammation  due  to  the 
deposit. 


EBSTEIN'S  THEORY  63 

Professor  Ebstein  also  studied  the  deposition  of  urates 
in  fowls  after  ligature  of  the  ureters,  or  after  progressive 
abolition  of  the  renal  function  by  injections  of  chroniate  of 
potassiiim.  Sir  W.  Roberts  has  shown  that  in  them  the 
biurate  is  precipitated  in  the  tissues  in  the  gelatinous 
form,  whereas  in  mammals  the  concentration  is  never 
sufficient  to  allow  the  gelatinous,  but  only  the  crystalline 
variety  to  be  precipitated. 

That  the  case  of  fowls  and  that  of  man  are  not  com- 
parable is  further  illustrated  by  the  fact  that  Ebstein 
describes  deposits  in  the  liver  and  muscles  in  fowls,  situa- 
tions in  which  they  do  not  occur  in  human  gout. 

In  conclusion,  Ebstein  does  not  identify  the  uric  acid 
as  a  direct  local  decomposition  product  of  the  tissues. 
The  share  of  the  latter  in  the  process  is  limited  to  the 
faulty  metabolism  of  muscles  and  marrow  which  supplies 
the  excess  of  uric  acid,  and  to  the  local  precipitation  of 
the  biurate  through  the  acidity  due  to  the  local  necrosis. 
The  theory  of  the  direct  histogenous  derivation  of  uric 
acid,  formerly  hinted  at  by  Laycock  and  by  Parkes,  and 
taught  more  definitely  by  Ord,  did  not  reach  maturity 
until  Professor  Latham  worked  out  a  chemical  explanation 
of  the  process,  and  Horbaczewski  demonstrated  the  steps 
in  the  transformation  of  nuclein  into  uric  acid. 


CHAPTER  X. 

THE  'NERVOUS'  THEORIES  OF  GOUT. 

The  middle  of  the  last  century  witnessed  a  reaction 
against  the  humoral  theory  which  had  long  prevailed, 
and  a  revival  of  solidism.  Stahl's  great  work*  is  regarded 
as  the  starting-point  of  the  modern  speculation  as  to  the 
nervous  origin  of  gout. 

Following  this  lead,  Cullen  t  threw  the  weight  of  his 
clinical  experience  and  authority  into  the  scale.  Gout 
was  considered  by  him  to  be  a  disease  primarily  of  the 
nervous  system. 

Again,  at  a  much  later  date,  in  1847,  Henle  took  up  the 
same  idea,  and  taught  that  '  the  origin  of  the  affection 
was  probably  to  be  found  in  the  central  nervous  system.' 

Professor  Gairdner,:];  whose  philosophical  work  appeared 
soon  after  the  publication  of  Garrod's  theory  of  renal 
inadequacy,  endeavoured  to  trace  the  defective  elimina- 
tion of  uric  acid  as  a  result  of  some  more  distant  cause, 
and  found  suggestive  analogies  in  the  check  to  the  renal 
function  induced  by  shock,  emotion,  and  hysteria.     Pro- 

*  'Theoria  Medica  Vera,'  etc.;  G.  E.  Stahl  (Halle,  1737):  '  De 
Doloribus  Spasticis  Arthco-  Podagricis,'  §  xxxviii.,  p.  1040  (quoted  by 
Duckworth). 

t  First  lines  of  the  '  Practice  of  Physic,'  1784  :  vol.  ii.,  part  i., 
chap.  xiv. 

I  '  On  Gout :  its  History,  its  Causes,  and  its  Cure,'  by  William 
Gairdner,  M.D.  ;  London  :  J.  Churchill,  1849. 


'NERVOUS'  THEORIES  65 

fessor  Gairdner  may  thus  claim  to  have  been  in  eifect, 
without  at  the  time  exphcitly  asserting  that  position,  one 
of  the  earhest  supporters  of  the  modified  nervous,  or 
neuro-humoral  theory  of  gout,  or,  at  any  rate,  of  the 
view  that  the  nervous  system  is  impHcated  in  the  patho- 
logical events. 

Various  other  observers,  recognising  the  directive 
influence  exercised  on  other  tissues  by  the  nervous 
system,  took  up  a  similar  position.  Laycock  was  a  strong 
believer  in  the  influence  of  altered  innervation. 

The  nervous  theory  of  gout  has  another  prominent  advo- 
cate in  Dr.  Edward  Liveing,*  who  sees  in  its  paroxysmal, 
periodic,  and  other  features  reason  to  suspect  a  nervous 
origin  of  the  disease. 

Within  recent  years  a  fresh  impulse  has  been  given  in 
the  same  direction  by  Dr.  Ord's  observations  of  a  nervous 
factor  in  some  affections  of  the  joints;  by  Dr.  Buzzard's 
suggestion  of  a  centre  for  the  nutrition  of  joints,  which  he 
would  localize  in  the  region  of  the  fourth  ventricle  rather 
than,  as  Charcot  had  been  led  to  think  by  the  frequent 
association  of  tabetic  joint  trouble  with  gastric  crises,  in 
the  anterior  cornua  of  the  spinal  cord ;  and  by  Professor 
Latham's  assumption  of  some  central  affection  of  the 
nervous  system,  by  which  he  seeks  to  explain  the  altered 
hepatic  metabolism  which  he  regards  as  the  immediate 
cause  of  the  gouty  trouble. 

DUCKWORTH'S  THEORY— GOUT  AS  A   TROPHO- 
NEUROSIS. 

The  latest  exponent  of  the  nervous  theory,  Sir  Dyce 
Duckworth,  t  had  claimed  as  far  back  as  1880  J  a  neurotic 

*  '  On  Megrim,  Sick-Headache  and  some  Allied  Disorders,'  p.  4.04  ; 
London,  1873. 
f  'A  Treatise  on  Gout ;'  London,  1889.         J  Brain,  April,  1880. 

5 


66  DUCKWORTH'S  THEORY 

origin  for  gout.  He  describes  gout  as  '  a  primary  neurosis,' 
'  a  functional  disorder  of  a  definite  tract  of  the  nervous 
system.'  '  In  primary  or  inherited  gout  the  toxaemia  is  de- 
pendent on  the  gouty  diathesis.  In  secondary  or  acquired 
gout  it  is  directly  induced  by  such  habits  as  overload  the 
digestive  and  excretory  organs,  and  constantly  prevent 
complete  secondary  disposal  of  the  nutritional  elements 
of  food.  If  then,  together  with  such  toxaemia,  distinctly 
depressing  and  exhausting  agencies,  affecting  the  nervous 
system,  come  into  operation,  the  special  neurotic  mani- 
festations of  the  gouty  diathesis  will  occur,  and  be 
impressed  more  or  less  deeply  upon  the  individual  and 
his  offspring.'  By  neurosis  he  understands  '  a  peculiar 
disposition  or  tendency  on  the  part  of  the  nervous  system, 
or  some  definite  tract  of  it,  towards  morbid  evolution  or 
manifestation  of  nerve  functions.' 

'  A  most  marked  feature  in  all  neurotic  affections  is  the 
paroxysmal  tendency.'  Other  features,  all  of  which  are 
traceable  in  gout,  are  periodicity,  instability,  and  alter- 
nations in  their  manifestations,  and  a  liability  to  be  excited 
or  aggravated  by  undue  nerve  strain  and  by  depression. 
In  all  these  respects  a  likeness  may  be  traced  between 
gout  and  a  typical  neurosis. 

Whilst  the  neurosis  is  the  nervous  agency  in  the  gouty 
attack,  the  gouty  habit  is  the  outcome  of  a  neuro-trophic 
defect. 

Entering  into  further  detail,  and  assuming  with  Ebstein 
'an  undue  formation  of  uric  acid  in  unusual  localities,'* 
and  with  Beneke,  Bouchard,  and  Rendu,  '  a  primordial 
vice  of  nutrition,'  '  a  peculiar  incapacity  for  normal  ela- 
boration of  food  within  the  whole  body,  whereby  uric 
acid  is  formed  at  times  in  excess,  or  is  incapable  of  being 
duly  transformed  into  more  soluble  and  less  noxious  pro- 
*  E.g.,  bone  and  muscle. 


GOUr  A  TROPHO-NEUROSIS  67 

ducts,'  Sir  Dyce  Duckworth  ascribes  this  disability  to 
disturbed  innervation,  and  to  '  perverted  neuro-trophic 
functions,'  i.e.,  to  a  tropho-neurosis. 

From  this  description,  it  will  be  readily  gathered  that 
the  nervous  theories  entertained  by  some  modern  patho- 
logists, and  in  particular  by  Sir  Dyce  Duckworth,  are 
of  a  mitigated  type  ;  they  are  considerably  toned  down 
from  the  uncompromising  type  originated  by  Cullen.  A 
humoral  aspect  of  gout  is  freely  admitted  by  all,  and  the 
humoral  changes  are  freely  discussed.  Thus,  Sir  Dyce 
Duckworth  expressly  states,  '  I  cannot  dissever  the  two 
ideas,  and  hence  I  affirm  that  gout  is  a  neuro-humoral 
disease.'  Still,  he  looks  beyond  the  chemical  pathogeny 
of  gout  for  '  a  presiding  nervous  element,'  and  he  finds  it 
in  the  neurosis,  which  may  be  either  '  implanted,'  that  is, 
primarily  impressed  as  an  individual  heritable  feature,  or 
'  secondarily  induced,  owing  to  some  toxasmic  condition.' 

On  the  other  hand,  the  toxaemia  itself  reacts  on  the 
nervous  system  in  a  secondary  fashion,  aggravating  the 
natural  tendency.  In  the  same  way,  in  acquired  gout 
also,  the  nervous  system  gradually  falls  under  the  influence 
of  that  weakness,  which,  though  not  itself  a  neurosis, 
ends  in  producing  the  gouty  neurosis,  and  in  being 
capable  of  hereditary  transmission. 

This  inherited  predisposition  to  the  gouty  tropho- 
neurosis is  part  of  a  still  wider  peculiarity  of  the  indi- 
viduum  recognised  by  Sir  Dyce  Duckworth  as  the  arthritic 
diathesis,  or  arthritism,  and  consisting  in  a  special  vulner- 
ability of  the  'joints  and  other  structurally  allied  tissues, 
and  in  their  special  liability  to  trophic  changes,'  asso- 
ciated with  a  marked  sensitiveness  to  changes  of  tempera- 
ture, soil,  and  climate.  He  regards  arthritism  (which 
was  originally  defined  by  Pidoux,  and  subsequently 
adopted  by  Charcot  and  recognised  also  by  Hutchinson) 


68  WADE'S  NEURAL  THEORY 

as  '  a  diathetic  habit  of  body,  from  which  arise,  as 
branches,  two  main  and  distinct  classes  of  disorder,  com- 
monly recognised  as  gout  and  rheumatism.' 

As  regards  the  chemical  changes  in  the  blood  and  the 
structural  changes  in  the  articulations,  the  theory  under 
review  is  in  complete  agreement  with  the  views  pro- 
pounded by  modern  pathology,  which  are  described  under 
another  heading. 

It  was  necessary  to  enter  into  a  detailed  consideration 
of  the  nervous  section  of  this  working  hypothesis,  because 
it  represents  the  most  complete  theory  published  in  this 
country  on  the  general  pathology  of  gout,  and  because 
the  able  advocacy  of  its  propounder  has  given  it  the 
support  of  arguments  derived  from  pathological  analogy 
and  from  clinical  inference,  which  will  demand  careful 
examination  and  searching  criticism  before  they  can  be 
either  disproved  or  adopted. 

WADE'S  NEURAL  THEORY  OF  GOUT. 

The  latest  addition  to  the  nervous  theories  of  gout  is 
Sir  Willoughby  Wade's  important  '  neural  theory.'  Its 
exposition,  involving  a  detailed  account  of  original  clinical 
observations,  will  be  more  profitably  undertaken  in  the 
Clinical  Section,  to  which  the  reader  is  referred.  Gout, 
according  to  the  neural  theory,  is  not  a  mere  neurosis, 
but  largely  partakes  of  the  characters  of  a  neuritis. 

Taking  into  account  the  shortness  of  the  acute  attack, 
at  any  rate  as  regards  the  pain,  it  will  probably  be  asked 
whether  the  changes  special  to  neuritis  would  have  time  to 
evolve  and  to  disappear  within  so  brief  a  period.  This  and 
other  criticisms  must,  however,  be  deferred  till  the  theory 
itself  has  been  more  fully  set  forth. 


III. 
THE  CHEMISTRY  OF  GOUT. 


CHAPTER  XI. 

SIR  WILLIAM  ROBERTS'  INVESTIGATIONS  ON 

THE  PHYSIOLOGICAL  AND  PATHOLOGICAL 

CHEMISTRY  OF  URIC  ACID. 

URIC  ACID  IN  THE  BLOOD. 
The  percentage  of  uric  acid  in  the  blood  in  health  is  very- 
small.  At  any  rate,  the  thread  experiment  does  not  suc- 
ceed in  showing  its  presence  in  most  cases.  During  the 
attack  of  gout  the  amount  can  be  easily  estimated.  Sir 
A.  Garrod  found  in  a  patient  so  high  a  percentage  as 
I  in  5,714;  and  Sir  W.  Roberts  •  adopts  the  proportion  of 
I  in  6,000  as  representing  the  state  of  saturation.  By 
saturation  he  understands  a  percentage  such  that  any 
addition  to  it  will  lead  to  supersaturation  and  to  deposition 
of  uric  acid  from  the  blood.  According  to  him,  super- 
saturation  may  be  said  to  exist  when  lymph  or  synovia 
contains  i  in  6,000,  and  under-saturation  when  they  con- 
tain less  than  i  in  10,000  of  the  biurates. 

The  sentm,  or,  rather,  the  plasma,  is  regarded  by  both 
authorities  as  being  the  carrier  of  the  uric  acid. 

Sir   W.    Roberts'    experiments    were    conducted    with 
serum,  but  to  a  large  extent  also  with  artificial  serum.    He 


70  URIC  ACID  IN  THE  BLOOD 

made  the  important  observation  that  by  adding  to  water 
sodium  chloride  or  sodium  bicarbonate  in  the  proportion 
in  which  they  are  contained  in  serum  (neglecting  the  small 
proportion  of  sodium  phosphate,  which  was  found  experi- 
mentally not  to  exert  any  effect  on  the  solubility  of  the 
urates),  a  standard  solvent  could  be  prepared*  which  in 
experiments  reacted  in  the  same  manner,  with  uric  acid 
and  urates,  as  blood  serum,  traces  only  of  sodium  biurate 
being  dissolved  by  it  at  loo''  Fahr. 

The  chemical  state  in  which  the  uric  acid  is  held  in  the 
blood  was  originally  assumed  to  be  that  of  a  urate.  Sir 
W.  Roberts  has  endeavoured  to  trace  the  chemical  changes 
undergone  by  the  acid  during  the  passage  from  the  healthy 
to  the  gouty  state.  But  a  preliminary  acquaintance  with 
his  description  of  the  normal  chemistry  of  uric  acid  is 
essential. 


THE  SALTS  OF  URIC  ACID:  THEIR  CHANGES  AND 
THEIR  BEHAVIOUR. 

Uric  Acid,  the  Biurate  and  the  Quadrinrate. — Sodium 
biuratef  has  been  proved  by  Sir  W.  Roberts  to  be  peculiar 
to  gout,  never  existing  in  the  human  body  except  as  a 
by-product  of  the  disease. 

The  form  in  which  the  salts  of  uric  acid  are  circulated, 
secreted,  and  excreted,  is  that  of  the  quadriurate,  in  which 
a  double  molecule  of  uric  acid  is  associated  with  a  single 
molecule  of  a  monovalent  base.     Prior  to  Sir  W.  Roberts' 

*  Composition  of  the  standard  solvent  : 

Sodium  chloride o"5  gram. 

Sodium  bicarbonate      o'2      „ 

Distilled  water   ...         ...         ...         ...     loo     c.c. 

t  The  neutral  or  dimetallic  urate  is,  according  to  Sir  W.  Roberts, 
merely  a  laboratory  product,  and  never  occurs  in  the  normal  economy. 


THE  SALTS  OF  URIC  ACID  7^ 

researches,  this  compound  had  been  described  by  Bence 
Jones,*  but  his  discovery  had  been  forgotten. 
The  chemical  formula 

HsCCsHaN^Og),  MH(C5H2NP3) 
or 

H.U,  MHU. 

suggests  that  the  two  uric  molecules  are  conjugated  rather 
than  combined.  So  slight  an  influence  as  that  of  a  bulk 
of  water  suffices  to  separate  them,  and  to  cause  uric  acid  to 
crystallize.  The  molecule  of  metal  in  the  remainder  now 
becomes  the  centre  of  a  fresh  quadriurate  group,  which  in 
its  turn  will  be  split  up  ;  and  the  process  will  repeat  itself 
till  all  the  uric  acid  has  been  deposited.  This  reaction  is, 
therefore,  a  means  of  estimating  the  amount  of  uric  acid 
present  in  a  solution. 

Uric  Acid  as  a  Urinary  Sediment. — The  appearance  of 
uric  acid  crystals  in  urine  after  it  has  stood  is  shown  by 
Sir  W.  Roberts  to  be  due  to  the  process  described,  slightly 
modified  by  the  presence  of  sodium  and  potassium  phos- 
phates, which  assist,  nay,  compel,  the  reconversion  of  the 
separated  molecule  of  biurate  into  quadriurate,  thus, 

2MHU  +  MH2Po4  =  (H2U,  MHU)  +  M2HPo4, 

whilst  they  themselves  pass  into  the  alkaline  phase.  This 
change,  which  explains  the  inability  of  the  urine  to  hold 
uric  acid  as  a  biurate,  occurs  in  all  urines  eventually  ;  but 
the  constituents  of  any  particular  urine  exercise  an 
influence  on  the  time  at  which  the  reaction  takes  place. 

1.  A  high  percentage  of  uric  acid  greatly  predisposes 

to  precipitation. 

2.  The  alkaline  reaction  prevents  precipitation. 

*  '  On  the  Composition  of  the  Amorphous  Deposit  of  Urates  in 
Healthy  Urine,'  by  Henry  Bence  Jones,  Journal  of  the  Chem.  Soc, 
1862,  vol.  XV.,  p.  201. 


72  THE  GELATINOUS  MODIFICATIONS 


3.  Much  acidity  greatly  favours  it ;  hence  the  addition 

of  even  small  amounts  of  the  alkaline  carbonates 
will  delay  the  precipitation. 

4.  The  great  affinity  of  uric  acid  for  the  soluble  urinary 

pigment  probably  tends  to  keep  it  in  solution.  At 
any  rate,  earlier  precipitation  occurs  in  urines 
which  are  deficient  in  pigment. 

5.  Deficiency  in  salines,  and  particularly  in  common 

salt,  has  also  been  shown  by  Sir  W.  Roberts  to 
be  an  accelerating  influence. 

These  observations  have  an  important  bearing  upon  the 
pathology  and  treatment  of  calculus  and  gravel,  to  which 
further  reference  will  be  made. 

The  Gelatinous  Quadriurate. — The  quadriurate  possesses 
greater  solubility  than  either  uric  acid  or  the  biurate. 
Moreover,  its  solubility  varies  greatly  with  temperature. 
By  very  rapidly  cooling  the  solution  of  an  artificially  pre- 
pared quadriurate.  Sir  W.  Roberts  was  able  to  obtain  this 
body  in  a  gelatinous  form.  It  is  in  this  amorphous  variety 
that  the  quadriurate  is,  according  to  Sir  W.  Roberts,  cir- 
culated through  the  economy  in  health,  and  excreted  at 
the  kidney. 

The  Gelatinous  or  Amorphous  Biurate. — Greater  patho- 
logical interest  attaches,  however,  to  the  gelatinous  or 
hydrated  modification  of  the  biurate.  According  to  Sir  W. 
Roberts'  observations,  the  biurate  liberated  in  the  fashion 
described  above  from  solutions  of  the  quadriurates  by 
addition  of  water  is  set  free  originally  in  a  gelatinous  form, 
and  can  be  abundantly  obtained  by  saturation  with  chloride 
of  sodium  crystals  in  the  shape  of  spheres  analogous  to  the 
spheres  found  in  the  urine  of  birds  and  serpents,  which  is 
presumably  excreted  in  the  gelatinous  form. 

The  gelatinous  deposit  previously  obtained  by  Dr.  Ord* 

*  *  On  the  Influence  of  Colloids  upon  Crystalline  Form  and  Co- 
hesion,' by  W.  M.  Ord,  M.D.,  etc.  ;  London,  1879,  pp.  72  and  219. 


THE  MATURATION  OF  THE  BIURATE  73 

on  cooling  the  mixture  of  a  hot  saturated  solution  of  the 
ammonium  or  of  the  sodium  urate  with  strong  solution  of 
an  alkaline  chloride  or  phosphate,  and  regarded  by  him  as 
a  true  colloid,  analogous  to  the  colloidal  form  of  silica,  is 
considered  by  Sir  W.  Roberts  to  be  rather  an  instance  of 
hydration  of  a  salt,  for  he  was  able  to  pass  the  combina- 
tion unchanged  through  the  dialyser. 

Proceeding  to  a  further  study  of  this  spurious  colloid. 
Sir  W.  Roberts  discovered  that  it  represented  a  more 
soluble  form  of  the  biurate,  and  that  it  is  probably  formed 
when  sodium  biurate  is  dissolved  in  boiling  water.  Although 
ten  times  as  much  of  the  salt  is  then  taken  up  as  by  cold 
water,  no  precipitate  occurs  on  cooling  until  several  days. 
have  elapsed,  and  this  suggests  a  change  in  the  molecular 
state  of  the  compound.  In  truth,  the  biurate  is  readily, 
precipitated  in  the  gelatinous  form  from  the  cooled  filtrate 
on  saturation  with  the  chloride,  phosphate,  or  acetate  of 
the  fixed  or  of  volatile  alkalies  in  bulk,  or  in  concentrated 
solution,  or  by  means  of  a  20  per  cent,  solution  of  common 
salt ;  and  it  is  then  freely  soluble  in  blood  serum  at  100° 
Fahr.,  or  with  the  standard  solvent  (which  hardly  dissolves 
any  of  the  crystalline  biurate).  Eventually  the  gelatinous 
precipitate  (whether  in  the  solid. form  or  in  solution)  spon- 
taneously suffers  dehydration,  and  is  reconverted  into  the 
crystalline  variety,  as  originally  discovered  by  Dr.  Ord. 

The  Serial  Changes  undergone  by  the  Uric  Group,  or  the 
'  Maturation '  of  the  Crystalline  Biurate. — Sir  W.  Roberts 
shows  that  the  quadriurate  undergoes  in  the  blood,  lymph, 
and  synovia  changes  exactly  converse  to  those  described 
above  in  the  urine,  and  leading  to  the  deposition  of  sodium 
biurate  in  the  tissues.  He  has  satisfied  himself  that  '  uric 
acid  is  normally  taken  up,  circulated,  and  voided  as  a 
quadriurate.''  But  when  unduly  accumulated  and  detained 
through  renal  inadequacy,  as  in  the  gout}^  state,  in  contact 


74  THE  SOLUBILITY  OF  THE  BIURATE 

with  the  sodium  bicarbonate  of  the  blood,  it  is  partly 
transformed,  with  assumption  of  an  additional  atom  of 
base,  into  the  biurate,  which  is  at  first  gelatinous,  but, 
ultimately  becoming  dehydrated,  is  then  ready  to  be  pre- 
cipitated, as  this  occurs  in  gout,  in  the  crystalline  state. 
This  process  is  referred  to  as  the  '  maturation  '  of  the 
biurate. 

According  to  these  views,  the  gouty  process,  so  far  as  it 
relates  to  uratic  sedimentation,  might  be  explained  on  the 
basis  of  the  varying  degrees  of  solubility  of  the  compounds 
of  uric  acid  in  the  several  media ;  it  would  be  a  matter  of 
undersaturation  and  of  supersaturation.  The  conditions 
affecting  the  solubility  of  the  biurates  in  the  juices,  and 
particularly  in  the  blood,  the  lymph,  and  the  synovia,  thus 
acquire  special  importance. 

The  solubility  of  the  sodium  biurate  (pure,  artificially  pre- 
pared) in  water  was  found  to  be  about  i  in  looo  (at  ioo° 
Fahr.) ;  in  serum  it  was  about  i  in  10,000,  and  in  synovia 
similar  results  were  obtained. 

The  great  difference  in  the  solvent  power  of  the  two 
fluids  is  illustrated  by  Sir  W.  Roberts'  experiment.  Two 
gouty  incrusted  metatarsal  bones  were  respectively  kept 
immersed  in  6  oz.  of  blood  and  in  6  oz.  of  pig's  serum, 
at  blood-heat.  The  uratic  deposit  in  the  latter  case  was 
not  completely  dissolved  until  fifteen  months — although 
the  serum  was  three  times  renewed — whereas  four  days 
sufficed  when  water  was  used. 

Saline  solutions  of  varying  strength,  namely,  the  bicar- 
bonate, the  chloride,  the  sulphate,  the  phosphate,  and 
the  acetate  of  sodium,  the  bicarbonate,  chloride  and  sul- 
phate of  potassium,  the  chloride  of  ammonium,  and  the 
chloride  and  the  sulphate  of  calcium  and  of  magnesium, 
were  tested  as  to  their  behaviour  as  solvents  of  uric  acid, 
with  unexpected  and  remarkable  results. 


THE  INFLUENCE  OF  THE  MEDIUM  75 

1.  A  general  observation  is  applicable  to  all  these  salts  ; 
'  alkalinity  or  neutrality  of  the  medium  has  not  the  slightest 
influence  on  the  result.' 

2.  The  salts  of  sodium  strongly  and  uniformly  (namely, 
in  proportion  to  the  sodium  which  they  contained) 
diminished  the  solvent  power,  for  sodium  biurate,  of  the 
medium  to  which  they  were  added,  a  maximum  effect, 
to  which  greater  concentration  added  little,  being  pro- 
duced, in  the  case  of  the  chloride  and  of  the  bicarbonate, 
by  solutions  containing  o'5  per  cent, 

3.  The  salts  of  potassium  were  found  to  be  absolutely 
inert  as  regards  any  influence  on  the  solubility  of  the 
sodium  biurate.  Their  solutions,  of  whatever  strength  up 
to  a  strength  of  0*5  or  of  i  per  cent.,  take  up  precisely  as 
much  of  the  biurate  as  does  distilled  water. 

4.  The  salts  of  calcium  resemble,  but  do  not  equal, 
those  of  sodium  in  their  checking  action  on  the  solubility 
of  the  biurate  of  sodium. 

5.  The  salts  of  magnesium  act  likewise  in  an  adverse 
direction,  although  the  effect  is  a  much  slighter  one,  and 
assimilates  them  more  closely  to  the  potassium  group. 

6.  The  salts  of  ammonium  occupy  an  intermediate 
position  between  the  calcium  and  the  magnesium 
groups. 

We  now  pass  to  the  process  of  maturation,  which  has 
been  stated  to  comprise  :  (i)  a  conversion  of  the  original 
quadriurate  into  the  hydrated  biurate ;  (2)  the  dehydra- 
tion of  the  latter  into  the  crystalline  biurate  ;  (3)  the  pre- 
cipitation of  the  anhydrous  salt.  It  was  experimentally 
shown  by  Sir  W.  Roberts  that  maturation  is  hastened  by 
warmth,  and  that  cold  does  not,  as  might  have  been 
assumed,  accelerate  the  act  of  precipitation. 

The  Influence  of  Various  Salines  on  the  Progress  of  Matu- 
ration.— The  influence  of  saline  solutions  studied   in  an 


76  MATURATION  HASTENED  OR  DELAYED 

extensive  series  of  observations  (with  the  microscope  as 
well  as  with  the  naked  eye)  gave  the  following  results : 

1.  Sodium  salts   (whether  of  alkaline  or  of  neutral 

reaction)  hastened  considerably  the  precipitation 
within  the  maturating  medium. 

2.  The  salts  of  potassium   '  sensibly  retarded  preci- 

pitation, but  did   not  appreciably  diminish  the 
eventual  amount  of  it.'* 

3.  '  Colchicum  and  magnesium  salts  appeared  to  delay 

precipitation,  but  their  action  in  this  respect  was 
quite  insignificant,  or  even  doubtful.' 

4.  '  The  salts  of  lithium  had  not  the  slightest  influence 

either  way.' 

5.  '  Piperazine  and  its  chloride  exercised  no  influence 

on  the  advent  of  precipitation.' 
The  Influence  of  Concentration. — By  far  the  most  important 
accelerating  influence  is  a  high  proportion  of  uric  acid. 
According  to  the  amount  present,  he  describes  two  forms 
of  precipitation,  which  he  assumes  to  have  their  counter- 
part in  the  joints  : 

1.  A  copious  and  sudden  precipitation  (impregnation 

with  uric  acid  i  in  2,500). 

2.  A  slow  and  scanty  precipitation  (impregnation  with 

uric  acid  i  in  5,ooo).t 
In  the  latter  case,  the  needles  are  extremely  thin  and 
short  (one,  two,  or  three  times  the  diameter  of  a  red  cell), 
and  are  held  to  be  probably  incapable  of  setting  up  acute 
inflammation,  though  perhaps  capable  when  occurring  in 
the  blood,  or  tissues,  of  producing  the  clotting  of  phlebitis 
or  the  symptoms  of  larval  or  irregular  gout. 

*  In  the  case  of  the  potassium  as  well  as  of  the  sodium  salts,  the 
results  were  solely  governed  by  the  nature  and  quantity  of  the  basic, 
to  the  exclusion  of  any  influence  from  the  acidulous  radical. 

t  I  in  5,714  was  the  proportion  found  in  a  gouty  patient  by  Sir  A. 
Garrod. 


THE  ARTIFICIAL  'GOUTY  FIT'  77 

Thus  the  originally  solvent  action  of  blood  serum  or  of 
the  standard  solution  is  followed,  when  opportunity  is 
given  for  the  gradual  incorporation  of  more  metal,  by  the 
formation  of  a  biurate  which  eventually  crystallizes  in 
needles.  By  treating,  according  to  this  method,  blood 
serum  from  the  horse  with  an  excess  of  uric  acid.  Sir 
W.  Roberts  was  able  to  obtain  a  close  imitation  of  the 
events  in  a  '  fit  of  the  gout ' — '  firstly,  an  impregnation  of 
the  medium  with  sodium  quadriurate  ;  secondly,  a  period 
of  incubation  or  maturation,  during  which  the  quadriurate 
passes  into  biurate  ;  thirdly,  somewhat  sudden  precipita- 
tions of  sodium  biurate  in  the  crystalline  form ;  and  lastly, 
restoration  of  the  medium  to  comparative  purity  ;'  for  at 
the  end  of  the  experiment  on  the  fourth  day,  the  supernatant 
serum  in  the  corked  phial  was  found  to  be  comparatively 
free  from  uric  acid. 


CHAPTER  XII. 

THE   CHEMICAL   FACTORS  APPLIED   TO  THE 
EXPLANATION  OF  GOUT. 

I.  THE  LOCAL  PRECIPITATION  OF  THE  BIURATE. 

The  Chemical  Factors  influencing  the  Uratic  Precipitation. — 
The  chemical  factors  pointed  out  in  the  preceding  study 
as  favouring  uratic  deposition  being  excess  of  urates  and 
excess  of  sodium  salts,  the  importance  of  the  differences 
between  the  various  fluids  and  tissues  of  the  body  as  to 
their  richness  in  sodium  salts,  which  are  shown  in  the 
following  table  collated  by  Sir  W.  Roberts,  will  be  mani- 
fest: 

Percentage  of  Sodium  Salts. 


Per  cent. 

Per  cent 

Blood  serum     ... 

...     070 

Blood  corpuscles 

...      0"20 

Lymph       

. . .     070* 

Brain    

...      0"20 

Synovia      

...     o-8o 

Muscle 

...    o-o8 

Cartilage   

...     090 

Spleen 

...     o"o4 

Fibrous  tissue  ... 

...     070 

Liver    

...      0"02 

Among  the  tissues,  brain  and  muscle  seem  predestined 
to  escape,  and  cartilage  and  fibrous  tissue  to  incur,  the 
uratic  infiltration — an  arrangement  of  a  distinctly  con- 
servative tendency.  Among  the  fluids,  synovia  has  the 
highest  percentage  of  sodium.     Its  special  proneness  to 

*  Or  o'8o,  Munk  and  Rosenstein  (Maly's  Jahresbej-icht^  Bd.  xx., 
p.  40). 


LOCAL  PRECIPITATION  OF  THE  BI URATE  79 

become  the  seat  of  uratic  precipitation  was  demonstrated 
in  Sir  W.  Roberts'  'maturation'  experiments. 

When  synovia  (the  relatively  thinner  synovia  from  the 
hip-joint  of  the  ox)  w^as  used,  the  same  changes  occurred 
as  in  the  case  of  blood-serum  ;  but  the  precipitation  of  the 
biurate  began  distinctly  earlier,  a  circumstance  correlated 
with  the  larger  amount  of  salts  contained  in  synovia. 

A  post-mortem  infiltration  of  the  upper  layer  of  the 
cartilage  was  induced  in  the  tarsal  bones  of  a  pig  by  sus- 
pending them  at  the  ordinary  temperature  in  a  previously 
boiled,  saturated  solution  of  sodium  biurate,  which  suffered 
precipitation  in  two  or  three  days. 

Moreover,  the  same  conclusion  is  supported  by  observa- 
tion in  the  human  subject.  Crystals  of  sodium  biurate 
have  often  been  found  in  synovial  fluid  ;  and  it  is  for  Sir 
W.  Roberts  matter  of  demonstration  that  the  deposition 
proceeds  from  the  synovial  fluid,  and  does  not  originate  in 
the  cartilage,  but  is  equivalent  to  a  passive  infiltration, 
and  therefore  more  common  and  abundant  at  those  points 
(at  the  periphery  of  the  cartilages)  where  the  synovia  is  in 
more  constant  contact. 

Sir  W.  Roberts  infers  that  deposits  within  the  fibrous 
and  tendinous  structures  are  Ukewise  passively  induced 
from  the  synovia,  and  do  not  depend  upon  any  primar}^ 
local  morbid  changes  in  the  tissues. 

The  Influence  of  Tissues  and  of  Locality. — The  connective 
tissues,  which  are  almost  exclusively*  those  liable  to  gouty 
deposit,  do  not  suffer  equally  in  all  situations.  Those 
which  enter  into  the  formation  of  joints  and  are  bathed 
in  synovia  are  much  more  exposed,  and  among  the  joints 
the  more  superficial,  and  those  least  protected  against  the 
influence  of  cold,  suffer  most. 

*  The  muscular  tissue,  and  the  substance  of  the  brain,  Hver,  spleen 
and  lung  are  conspicuously  exempt.     The  kidney  sufifers. 


8o  LOCAL  PRECIPITATION  OF  THE  BIURATE 

A  combination  of  these  factors,  with  a  general  excess  of 
uric  acid  in  the  system,  would  act  in  the  most  potent  way, 
as,  for  instance,  when  general  saturation  of  the  blood 
happened  to  coincide  with  a  local  excess  of  sodium  salts  ; 
that  locality  would  then  become  the  seat  of  the  uratic 
deposit. 

Sir  W.  Roberts  throws  out  the  further  important  sugges- 
tion that  in  proportion  as  the  fluids  in  the  several  joints 
differ  in  concentrations,  so  also  will  the  joints  differ  in 
their  liability  to  uratic  concretions. 

The  assumption,  made  by  Sir  A.  Garrod  and  others,  of 
a  special  attraction  for  uric  acid  in  the  joints,  is  at  present 
beyond  the  range  of  proof.  On  the  other  hand,  definite 
mechanical  factors  are  suggested  by  Sir  W.  Roberts  in 
explanation  of  the  facts,  viz.,  (i)  the  relatively  motionless 
condition  of  the  synovia ;  (2)  the  concentration  of  the 
synovial  fluid,  varying  in  different  joints,  and  varying  also 
in  any  one  joint  at  different  times,  not  only  (as  originally 
pointed  out  by  Frerichs)  under  the  influence  of  rest  and 
of  work — the  latter  leading  to  a  smaller  bulk  and  a  greater 
concentration — but  perhaps  also,  as  ingeniously  imagined 
by  Sir  W.  Roberts,  owing  to  general  dehydrating  influences, 
such  as  that  of  a  heavy  meal  accompanied  with  copious 
libations  of  undiluted  wine,  or  conceivably  to  some  local 
dehydration,  such  as  may  be  among  the  immediate  effects 
of  an  injury  to  a  joint ;  (3)  the  large  proportion  of  mineral 
salts  (almost  exclusively  those  of  sodium)  special  to  synovia. 

The  Influence  of  General  Excess  of  Uric  Acid. — In  explana- 
tion of  the  systemic  factor  essential  to  a  precipitation  of 
uric  acid,  viz.,  its  accumulation  in  the  blood.  Sir  W.  Roberts 
recognises  with  Sir  A.  Garrod  a  partial  loss  of  secreting 
power  of  the  renal  cell  for  uric  acid  only,  and  not  for  other 
constituents  of  the  urine.  Lead  impregnation,  or  premature 
senescence,  or  any  other  '  depressors  of  the  uric  acid  excre- 


LOCAL  PRECIPITATION  OF  THE  BIURATE  8i 

tion,'  might  readily  lead  to  minute  but  cumulative  daily 
arrears  in  the  amount  of  uric  acid  removed,  and  saturation 
of  the  blood  with  urates  would  be  inevitably  induced. 

In  some  individuals  whose  arrearage  is  habitual  and 
inveterate,  the  frequency  of  the  recurring  attacks  of  pre- 
cipitation into  the  fibrous  structures  is  '  providential  and 
protective.'  In  a  second  group  the  loss  of  adjustment  is 
an  infrequent  and  almost  accidental  '  mischance ' ;  these 
are  favourable  cases  in  which  persevering  treatment  will 
succeed  in  preventing  a  recurrence  of  precipitation,  or  in 
reducing  its  frequency  and  extent ;  but  in  the  iirst  group, 
the  permanent  character  of  the  renal  defect  makes  it  '  vain 
to  expect  that  we  can  redress  the  balance,  and  restore  the 
equilibrium  between  production  and  elimination.' 

'  Gentle  sprinklings '  of  the  sodium  biurate  in  its  finest 
and  most  minute  crystalline  form,  occurring  in  the  most 
varied  situations,  would  best  explain  the  manifold  visceral 
and  neurotic  disturbances  noticed,  as  well  as  the  '  pricking 
pains  in  the  joints'  induced  in  certain  subjects  by  particular 
wines. 

The  Re-solution  of  Uratic  Deposits. — This  eventuality  also 
finds  its  explanation  in  Sir  W.  Roberts'  observations  and 
theory.  Assuming  that,  during  the  often  long  intervals 
between  the  outbreaks,  the  blood  and  the  synovia  regain 
their  purity,  '  since  the  solvent  relation  of  the  bodily  fluids 
to  the  material  of  gouty  deposits  is  simply  a  question  of 
saturation  or  of  subsaturation,'  the  sodium  biurate  will 
undergo  re-solution ;  and  it  may  chance  that  a  joint 
formerly  the  seat  of  gout  may,  at  death,  present  no  trace 
of  the  biurate ;  indeed,  this  change  may  be  watched  pro- 
ceeding during  life  in  the  pinna  of  the  ear,  where  tophi  are 
seen  to  come  and  go. 

Conversely,  a  joint  found  infiltrated  with  biurates  after 
death   is   not  thereby  proved  to  have  been    the  seat  of 

6 


82  LOCAL  PRECIPITATION  OF  THE  BIURATE 

inflammation.  It  would  be,  of  course,  easier  for  fibrous 
tissues  to  be  cleared  of  their  deposit  than  for  cartilages. 

Precipitation  of  Uric  Acid  in  the  Individital  Tissues. — We 
may  now  briefly  review  the  subject  of  uratic  precipitation 
with  reference  to  the  several  tissues  or  organs. 

In  the  blood  itself,  so  long  as  it  preserves  its  alkalinity, 
uratic  precipitation  is  excluded.  In  an  opposite  phase  of 
reaction,  precipitation  would  occur  so  soon  as  an  excess  of 
uric  acid  chanced  to  accumulate.  Of  the  occurrence  of 
this  combination  of  circumstances  we  possess  at  present  no 
actual  proof.  Any  precipitation  which  might  conceivably 
occur  in  the  bulk  of  the  blood  would  be  in  the  shape  of 
very  minute  particles,  and  these  would  probably  be  dealt 
with,  as  most  other  floating  material,  by  the  scavenger 
cells,  and  disposed  in  any  of  the  collecting  organs. 

The  special  liability  of  all  connective  tissues,  but  particu- 
larly of  the  fibrous  structures  within  and  about  joints  and 
of  the  articular  cartilages,  has  been  connected  with  the 
relative  inactivity  of  their  blood  circulation,  and  with  their 
dependence  upon  nutritional  exchanges  with  lymph  or 
synovia,  both  fluids  being  more  susceptible  of  sufl"ering 
locally  a  loss  of  alkalescence,  and  of  solvent  power  for  uric 
acid,  than  blood.  Moreover,  Sir  W.  Roberts  has  shown 
that  synovia  favours  precipitation  of  biurate  in  a  special 
degree,  owing  to  its  high  percentage  of  sodic  salts.  The 
combination  of  an  unyielding  texture,  as  in  cartilage  and 
in  fibrous  tissue,  with  superadded  pressure,  as  in  move- 
ments of  the  joints,  is  probably  an  additional  element  both 
in  the  damaging  effect  and  in  the  production  of  pain  ; 
much,  however,  of  the  latter  is  probably  due  to  the  tension 
induced  by  the  contingent  vascular  and  lymphatic  engorge- 
ments. At  any  rate,  a  considerable  amount  of  acicular 
deposit  may  exist  in  the  cartilage  without  giving  rise  to 
paia. 


LOCAL  PRECIPITATION  OF  THE  BIURATE  83 

The  damage  capable  of  arising  from  uratic  deposit,  as 
well  as  the  pain,  may  be  expected  to  be  greatest  where  the 
circulation  is  least  active,  and  therefore  deposition  is 
rendered  easier  and  reabsorption  more  difficult. 

The  subcittmieoiis  connective  tissue  is,  next  to  the  joints 
and  their  fibrous  surroundings,  the  most  common  site  for 
precipitation ;  and,  as  elsewhere  described,  the  deeper 
layer  of  the  cutis  itself  may  be  involved. 

In  the  nerve  strnctiires  and  in  muscle  the  deposit,  when  it 
occurs,  is  probably  limited  to  the  connective  tissues,  and 
any  baneful  effect  felt  by  the  special  tissues  would  probably 
be  communicated  rather  than  direct. 

In  the  kidney,  the  deposit  is  supposed  to  occur  first  in 
the  connective  tissue  and  lymphatics,  and  later  in  the 
tubes ;  and,  except  by  Ebstein  and  others,  the  mechanical 
irritation  set  up  by  the  biurate  has  been  mainly  credited 
with  the  destructive  changes.  Here,  especially,  the  ques- 
tion of  alternations  between  precipitation  and  solution 
assumes  importance,  if  it  be  that  the  passage  from  one 
state  to  the  other  is,  as  suggested  by  Pfeiffer,  fraught  with 
.risk  to  the  neighbouring  cells. 

URIC  ACID  GRAVEL. 

Our  review  of  the  subject  of  uratic  precipitation  would 
not  be  complete  without  a  brief  sketch  of  the  subject  of 
gravel,  so  closely  allied,  both  chemically  and  clinically,  to 
the  subject  of  gout,  and  yet  entirely  distinct  from  it. 

The  factors  in  this  condition  are,  (i)  the  rate  of  forma- 
tion of  uric  acid,  and  (2)  the  rate  of  supply  of  its  natural 
solvents. 

In  gravel,  as  in  gout,  heredity  has  a  strong  influence, 
which  often  determines  the  onset  of  the  trouble  in  early 
childhood.     In  a  paper  on  '  Renal  Colic  in  Infants,'  read 


URIC  A  CID  GRA  VEL 


on  January  14,  i8g6,  before  the  Royal  Medical  and 
Chirurgical  Society,  Dr.  R.  A.  Gibbons  gives  details  of 
'  cases  occurring  in  infants  between  nine  and  twenty-three 
months,  in  which  all  the  symptoms  of  renal  colic  were 
present.  In  none  of  the  patients  was  a  distinct  calculus 
found,  but  there  was  abundance  of  free  uric  acid,  and  small 
masses  of  mortar-Hke  material  passed  consisting  of  uric 
acid  ;  and  the  urine  contained  blood.  In  all  the  cases 
detailed  there  was  a  strong  family  history  of  gout.  From 
the  facts  brought  forward,  it  is  clear  that  the  affection  is 
more  rarely  met  with  in  the  infants  of  the  poor,  and  that 
the  cause  of  this  is  due  to  the  greater  tendency  to  the 
inheritance  of  gouty  conditions  amongst  the  wealthier 
classes,  the  latter  being  more  prone  to  the  formation  of 
uric  acid,  and  to  suffer  from  conditions  classed  under  the 
name  "  gouty."  ' 

In  children  gravel  is  apt  to  produce  intense  restlessness, 
pain  often  in  the  umbilical  or  iliac  regions,  and  consider- 
able irritability  of  temper.  There  is  often  frequent  desire 
to  micturate,  and  ineffectual  rectal  tenesmus.  Dr.  Vaughan 
Harley,  in  a  valuable  paper  on  '  The  Chemical  Pathology, 
Symptoms,  and  Treatment  of  Uric  Acid  Gravel,'*  suggests 
that  in  doubtful  cases  the  fresh  morning  urine  should  be 
centrifuged  for  crystals  and  casts,  precipitation  of  uric 
acid  being  most  likely  to  take  place  from  the  '  urina  san- 
guinis '  secreted  after  the  alkaline  effect  of  the  last  meal 
has  long  passed  away.  Any  crystalline  sedimentation 
within  the  tubules  would  lead  to  irritation  of  their  lining 
cells,  and  probably  to  a  formation  of  casts,  and  to  the 
escape  of  albumin.  Indeed,  latent  uric  acid  precipitation 
of  this  kind  has  been  given  as  a  frequent  cause  of  func- 
tional or  cyclic  albuminuria. 

*  British  Medical  Journal-.  March  23,  1895. 


URIC  ACID  GRAVEL  85 

In  the  adult  the  symptoms  described  by  Dr.  Vaughan 
Harley  are  pain,  like  lumbago,  extending  down  the  ureters 
to  the  ovary  or  the  testicle,  with  frequent  desire  to  mic- 
turate. 

Impaction  of  gravel  in  the  ureters  is  often  so  painful  as 
to  simulate  peritonitis,  with  vomiting,  and  even  delirium. 

Slighter  symptoms  are  :  '  tender  feeling  '  over  the  loins, 
also  a  dull  pain  aggravated  by  any  new  position,  and 
relieved  only  by  lying  in  bed. 

Radiation  of  the  pain  occasionally  takes  place,  down  the 
arms  (Levison),  usually  down  the  legs,  and  especially  down 
the  front  of  the  thighs,  resembling  anterior  sciatica  in 
causing  the  knees  to  be  everted  and  the  heels  to  be  drawn 
up. 

Irregularity  of  the  heart  is  occasionally  present,  consti- 
pation usually  so.  Various  neuralgise  (migraine,  angina, 
asthma,  etc.)  are  also  described  by  Da  Costa. 

2.  THE  MECHANISM  OF  PRECIPITATION  OF  URIC  ACID 

IN  URINE. 

The  views  of  Sir  W.  Roberts  have  already  been 
described.*  The  automatic  splitting  up  of  the  quadri- 
urate,  under  the  influence  of  water,  into  uric  acid  and 
biurate  (the  latter  being  immediately  converted  into  a  fresh 
molecule  of  quadriurate  by  giving  up  half  its  base  to  the 
monobasic  phosphate)  would  rapidly  lead  to  a  precipita- 
tion of  the  greater  part  of  the  uric  acid,  whereas  normally 
no  precipitation  occurs.  He  connects  its  persistent  solu- 
bility in  normal  urine  with  the  presence  of  the  urinary 
salines  ;  and  he  specially  insists  on  the  influence  of 
common  salt  in  warding  off  precipitation,  and  attributes  to 
its  insufficient  supply  the  frequency  of  uric  acid  concre- 

*  Cf.  p.  71. 


86  PRECIPITATION  OF  URIC  ACID  IN  URINE 


tions  among  Hindoos,  whose  staple  of  diet  is  rice.  He 
also  points  out  the  action  exerted  by  the  urinary  pigments 
in  the  same  direction. 

A  somewhat  different  explanation  is  set  forth  by  Lieber- 
mann,  who  traces  in  the  kidney  substance  an  acid  reacting 
body,  acid  -  lecithin  -  albumin,  capable  of  converting 
Na2HP04,  or  other  alkaline  reacting  salts,  into  acid  salts, 
and  in  this  way  of  changing  the  reaction  of  blood  serum 
into  the  acid  phase.  By  using  a  layer  of  this  substance  as 
a  filter,  these  changes  can  be  brought  about  in  the  chemical 
laboratory ;  and  when  an  alkaline  sodium  phosphate  solu- 
tion is  injected  through  the  freshly-removed  kidney  of  a 
dog,  the  outflowing  fluid  is  found  to  be  acid. 

Meanwhile,  the  tissue  CO2  perpetually  comes  to  rescue 
the  acid-lecithin-albumin  from  its  alkaline  combination. 
Liebermann*  traces  an  analogy  between  the  behaviour 
of  the  mucous  membrane  of  the  kidney  and  that  of  the 
stomach. 

The  acid  of  the  urine  would  thus  be  conditioned  by  the 
available  amount  of  acid-lecithin-albumin  ;  and  the  avail- 
able amount  of  alkaline  phosphate  would  determine 
whether  the  soluble  urates  would  escape  being  broken  up 
by  the  renal  epithelium ;  or  whether  the  latter  would  split 
them  up  and  cause  a  crystalline  deposit  in  the  tubules ;  or 
whether,  lastly,  the  relative  deficiency  of  phosphates,  or 
the  relative  increase  of  urates,  would  lead  to  the  latter 
being  insoluble. 

Liebermann  further  inquires  whether  the  fact  that  the 

urine  of  herbivora  is  turbid  and  alkaline  may  not  be  due 

to  the  lecithin-albumin  in  their  kidneys  being  insufficient 

for  the  task  of  turning  into  the  acid  phase  the  alkaline 

salts  which  they  so  largely  take  in. 

*  Archiv.  fiir  die  Ges.  Physiologie,  1.,  p.  55.  €/.  Revue  des  Sciences 
Medicales,  1892,  vol.  xl,  p.  444. 


PRECIPITATION  OF  URIC  ACID  IN  URINE  87 

Tests  for  an  Excess  of  Uric  A  cid  in  Urine. — The  following 
rough  test  for  an  excess  of  uric  acid  in  limpid  urine  is  given 
by  Dr.  Vaughan  Harley* :  A  '  high-level '  precipitate  is 
normally  produced  by  cold  nitric  acid  in  healthy  urine,  but 
only  after  standing  from  five  to  ten  minutes.  When  the 
upper  cloud  forms  in  less  than  five  minutes,  the  urine  may 
be  regarded  as  unusually  prone  to  deposit  uric  acid  ;  if,  on 
the  contrary,  more  than  ten  minutes  should  elapse,  either 
the  amount  of  uric  acid  is  less,  or  its  solvents  are  present 
in  larger  quantity  than  usual. 

Pfeiffer's  uric  acid  filter  was  supposed  to  be  a  test  for 
the  gouty  character  of  urines,  and  to  supply  a  proof  of  the 
existence  of  a  relatively  insoluble  variety  of  uric  acid  in 
gout.  A  filter  upon  which  0*5  gramme  of  uric  acid  is 
placed  will,  according  to  Pfeiffer,  retain  the  uric  acid  of  the 
gouty  urine  which  is  made  to  pass  through  the  filter,  that 
of  a  healthy  urine  not  being  retained,  or  only  partly  so. 
Healthy  urine  would  require  a  much  larger  amount  of  uric 
acid  on  the  filter  (from  2  to  3  grammes).  Feliziani's 
determinations  do  not  support  these  statements.  Half  the 
number  of  gouty  urines  tried  by  him  did  not  respond  to 
the  test,  whilst  many  healthy  urines  responded  to  it.  Sir 
W.  Roberts  has  also  shown  that  any  urine,  whether  gouty 
or  not,  may  be  freed  from  uric  acid  by  repeated  filtration 
through  the  same  uric  acid  filter. 


OXALIC  ACID  AND  GOUT. 

Sir  A.  Garrodji*  who  demonstrated  the  presence  of  oxalic 
acid  in  the  blood  in  the  course  of  gouty  arthritis,  and  in 
two  cases  also  in  the  sweat,  regarded  it  as  derived  from 

*  Loc.  at,  p.  639. 

t  '  Med.  Chir.  Trans.,'  vol.  xxxii.,  1849. 


OXALIC  ACID  AND  GOUT 


the  oxidation  of  uric  acid — a  view  which  is  still  held  ; 
though,  as  pointed  out  by  Sir  Dyce  Duckworth,  other 
sources  must  exist,  as  shown  by  the  amount  being  often 
much  larger  than  would  correspond  to  uric  acid.  Its 
frequent  association  with  uric  acid  in  gouty  urine  is  pro- 
bably, however,  nothing  more  than  an  expression  of  the 
close  relationship  between  these  two  forms  of  acidity,  and 
of  the  practical  identity  between  the  dietetic  influences 
which  led  to  them.  Rhubarb,  sorrel,  tomatoes,  celer}^ 
watercress,  are  all  supposed  to  lead  to  oxaluria.  According 
to  Sir  Dyce  Duckworth,*  in  addition  to  these,  direct  pro- 
duction may  also  be  due  to  '  imperfect  oxidation  of  sac- 
charine, starchy,  and  oleaginous  principles  of  food  ;  to 
increased  tissue  metabolism,  whereby  the  fatty  acids  found 
in  excess  are  completely  reduced  ;  to  excess  of  lactic  and 
butyric  acid,  formed  in  intestinal  dyspepsia,  insufficiently 
reduced  ;  to  excess  of  mucin  in  the  urinary  channels,  which 
tends  to  foment  and  favour  deposition  of  oxalates  ;  and  to 
ingest  of  water  rich  in  lime  salts.' 

Oxalate  calculi,  which  are  less  frequent  than  uric  acid 
calculi,  are  often  partly  made  up  of  alternating  layers  of 
the  latter.  Prout  thought  they  were  apt  to  arise  after  an 
attack  of  gout.  He  pointed  out  that  oxaluria  was  also 
apt  to  alternate  with  an  increase  in  the  phosphate,  and 
especially  in  the  phosphate  of  lime,  which  might  amount 
to  phosphaluria. 

Boils  and  carbuncles  are  stated  by  Sir  Dyce  Duckworth 
to  occur  in  oxaluria,  as  they  often  do  in  glycosuria. 

Excess  of  oxalic  acid  is  not  directly  responsible  for  any 
of  the  complications  of  gout  ;  but  the  dietetic  factors 
leading  to  it,  the  hepatic  and  gastric  delicacy  which  may 
be  its  immediate  cause,  and  the  depression  so  often  attend- 


*  Loc.  cit.,  p.  197. 


OXALIC  ACID  AND  GOUT 


ing  upon  it,  are  so  many  points  of  contact  between  two 
diseases  which  run  parallel  courses  and  occasionally  over- 
lap.* 

*  The  latest  contribution  to  this  subject  is  an  exhaustive  paper  on 
'  The  Excretion  of  Oxahc  Acid  in  Urine,'  in  the /ountal  of  Pathology^ 
vol.  iii.,  January,  1896,  by  Dr.  J.  Craufurd  Dunlop,  who  states  that 
oxalic  acid  is  a  constant  constituent  of  urine  under  a  mixed  diet, 
averaging  "017  grm.  per  diem,  and  that  its  precipitation  as  calcium 
oxalate  occurs  in  about  one  urine  out  of  every  three  ;  that  it  is  not 
a  metabolic  product,  but  is  absorbed  from  the  alimentary  canal ;  and 
that  oxaluria  is  essentially  nothing  more  than  the  result  of  hyperacid 
dyspepsia. 


CHAPTER  XIII. 
THE  PATHOLOGY  OF  URIC  ACID. 

IS  URIC  ACID  TOXIC? 

Many  of  the  substances  contained  in  the  excretions  are 
toxic,  and  act  as  poisons  unless  removed  from  the  system 
without  delay.  Uric  acid,  minute  quantities  of  which  are 
normally  present  in  the  blood  in  soluble  combinations, 
accumulates  in  perceptible  proportion  under  the  influence 
of  gout.  In  gravel  and  calculus  it  occurs  as  a  precipitate 
in  the  urinary  passages,  and  in  gout  its  crystalline  salts 
are  deposited  in  the  parts  affected.  We  naturally  inquire 
whether  in  any  of  these  forms  it  is  capable  of  exerting  a 
toxic  action. 

As  a  solid,  uric  acid  itself  is  probably  inert,  and,  being 
sparingly  soluble,  may  lie  for  years  in  the  kidney,  ureter, 
or  bladder.  These  are  the  only  situations  in  which  it 
occurs.  In  all  other  localities  and  circumstances  (including 
the  administration  of  pure  uric  acid),  it  is  ultimately  with 
the  urates — and  largely  with  the  urate  of  sodium — that  we 
have  to  deal.  In  the  following  remarks  the  term  '  uric 
acid '  should  be  understood  to  apply  to  uric  acid  and  to 
its  combinations. 

The  urates  occur  in  the  crystalline  form  in  the  gouty 
deposits  (as  sodium  biurate) — as  well  as  in  solution  in  the 
blood  and  in  the  tissues  (as  quadriurates). 

By  most  authorities  the  action  of  the  solid  biurate  is 


IS  URIC  ACID  TOXIC?  91 

regarded  as  a  purely  mechanical  one,  and  much  of  the 
destructive  change  observed  in  the  joints  and  in  the  kidney- 
is  usually  explained  in  connection  with  the  irritating  shape 
of  the  crystals.  Mechanical  conditions  are,  for  Sir  W. 
Roberts,  a  sufficient  cause  for  the  incidents  of  regular  gout, 
and  for  their  varying  intensity,  which  would  be  determined 
by  the  amount  and  suddenness  of  the  precipitation  and  by 
its  situation  in  soft  and  loose,  or  in  unyielding  parts,  such 
as  the  lobe  of  the  ear  or  the  joints  respectively. 

The  insolubility  of  the  biurate,  although  great,  does  not 
compare  with  that  of  uric  acid  ;  and  it  has  been  asked 
whether  in  the  highest  state  of  concentration,  namely, 
immediately  before  or  immediately  after  precipitation,  a 
solution  of  the  salt  may  not  locall}'  exert  a  toxic  action. 
That  fluctuations  in  the  quality  of  the  juices  may  at  times 
lead  to  the  deposits  being  slowly  dissolved  again  is  clinically 
proved  in  the  case  of  tophi  in  the  auricle,  which  may  be 
seen  to  vanish,  and  anatomically  by  the  roughened  and 
pitted  condition  of  the  surface  of  cartilages,  from  which 
uratic  deposit  has  been  reabsorbed,  occasionally  found  in 
joints  which  had  formerly  been  the  seat  of  unequivocal 
gout.  The  juices  bathing  the  deposit  which  is  undergoing 
solution  may  be  fully  charged  with  biurate.  The  question 
is  thus  narrowed  down  to  the  case  of  the  urates  in  a  state 
of  solution. 

A  re  Urates  in  Solution  Toxic  ? — The  view  that  urates  are 
toxic  in  their  soluble  form  has  been  strongly  urged  by  two 
observers — Haig  and  Ebstein,  and  by  the  latter  they  have 
been  regarded  as  toxic  mainly  in  their  semi-fluid  or  gela- 
tinous state — that  which  immediately  precedes  their  pre- 
cipitation or  follows  upon  their  being  redissolved. 

According  to  Pfeiffer,  a  solution  of  pure  uric  acid  injected 
under  the  skin  acts  as  a  strong  irritant ;  but,  as  previously 
stated,  uric  acid  never  occurs  in  the  living  organism  in  this 


92  IS  URIC  ACID  TOXIC? 

form.  On  the  other  hand,  subcutaneous  injections  of  urates, 
though  they  may  set  up  some  pain  and  irritation,  entirely 
failed  in  his  hands  to  produce  necrosis. 

Haig,  who  dwells  with  special  emphasis  on  the  nerve 
intoxications,  has  bestowed  chief  attention  on  the  more 
soluble  condition  which  uric  acid  assumes  in  its  saline 
combinations  in  the  blood.  The  disturbing  properties  of 
uric  acid,  even  when  it  is  guarded  by  combination  with 
an  alkali,  is  illustrated  by  a  variety  of  sensations  and 
symptoms,  such  as  headache,  neuralgia,  general  discomfort, 
depression,  high  tension  of  the  pulse,  etc.,  which,  according 
to  him,  immediately  disappear  when  the  uric  acid,  being 
deprived  of  its  alkali  and  precipitated  into  the  collecting 
organs,  becomes  once  more  inert  and  non-poisonous. 

On  the  other  side,  the  latest  supporter  of  the  absolute 
innocuousness  of  uric  acid,  whether  in  solution  or  as  a 
deposit,  is  Professor  Bouchard,  who  adduces  experimental 
evidence  to  show  that  the  injection  into  rabbits  of  even 
large  quantities  of  uric  acid  produces  no  other  effects  than 
those  which  belong  to  the  injection  of  so  much  water, 
whilst  the  uric  acid  is  not  excreted  as  such,  but  in  the 
shape  of  an  increased  output  of  urea.  Similar  experiments 
and  conclusions  had  previously  been  arrived  at  by  other 
observers. 

Although  large  quantities  of  uric  acid  have  been  mixed 
with  the  food  or  injected  into  the  veins  of  animals,  the 
toxic  actions  ascribed  by  some  to  uric  acid,  in  explanation 
of  the  phenomena  of  irregular  gout,  have  never  received 
experimental  demonstration  ;  neither  does  the  gouty  man, 
saturated  with  uric  acid,  present,  on  the  eve  of  his  attack, 
any  of  those  symptoms  which  have  been  described  as 
resulting  from  uric  acid  intoxication. 

As  suggesting  a  non-poisonous  character  for  uric  acid, 
Sir  W.   Roberts   calls   attention    to   the  essentially  non- 


THE  ACCUMULATION  OF  URIC  ACID  93 

poisonous  character  of  its  homologue,  urea.  Drachm  doses 
can  be  swallowed  without  any  harm.  According  to  Dr. 
Rose  Bradford,  30  to  45  grains  are  always  present  in  the 
human  body,  and  often  much  larger  quantities,  without 
any  toxic  result. 

In  conclusion,  there  is  distinct  evidence  that  even  large 
doses  of  uric  acid  fail  to  produce  severe  toxic  results, 
though  they  may  lead,  according  to  Dr.  Haig,  to  nerve 
discomfort  and  visceral  symptoms.  Evidence  is  still  want- 
ing to  confirm  Ebstein's  statement  that  concentrated  solu- 
tions of  urates  will  lead  to  a  necrosis  of  tissues. 

THE  ACCUMULATION  OF  URIC  ACID. 

The  accumulation  of  uric  acid  in  the  blood.  Sir  A. 
Garrod's  fundamental  fact,  is  universally  recognised  as 
part  of  the  gouty  attack,  but  it  has  never  been  fully 
explained.  Sir  A.  Garrod's  own  explanation  is  that  there 
occurs  a  temporary  or  a  permanent  renal  inadequacy,  a 
check  to  the  excretion  of  uric  acid,  and  that  the  latter 
accumulates  in  the  blood  and  leads  to  all  the  symptoms  of 
.  gout. 

This  is  also  the  view  adopted  by  Dr.  Haig,  though  he 
does  not  limit  the  evil  results  of  the  circulation  of  uric 
acid  to  gouty  symptoms,  but  traces  to  it  many  other 
troubles.  In  gout  he  estimates  the  yearly  accumulation  of 
uric  acid  in  the  body  at  400  grains.  Other  observers, 
including  Salomon*  and  Von  Jaksch,-f-  have  fully  con- 
firmed Sir  A.  Garrod's  discovery. 

The  state  in  which  uric  acid  is  contained  in  the  blood 
has  not  been  experimentally  determined  ;  it  is  probably 

*  Charite  Anjtalen^  187B,  p.  137-  Salomon  detected  uric  acid  in  the 
blood  of  three  patients  during  the  attack,  but  was  unable  to  find  any 
during  the  intervals. 

t   Ueber  die  Klin.  Bedetefung  der  Harnsaure,  1890. 


94  THE  ACCUMULATION  OF  URIC  ACID 

variable.  It  has  hitherto  been  invariably  admitted  as  a 
chemical  necessity  bound  up  with  the  alkalinity  of  the 
blood,  that  any  uric  acid  it  may  contain  must  be  present 
as  a  salt ;  and  there  can  be  no  doubt  that  this  is  the  usual 
condition.  Still,  in  view  of  the  elementary  state  of  our 
knowledge  of  the  blood,  and  of  the  acquired  fact  that  the 
blood  may  be  sometimes  faintly  acid,  we  should  avoid  any 
exclusive  statement.  Assuming  that  the  uric  acid  generally 
occurs  in  the  combined  state,  we  are  quite  unable  to  define 
its  precise  chemical  position  and  its  relations  to  the  plasma 
and  to  the  blood-cells  respectively.  The  chemical  estima- 
tions tell  us  of  its  presence  and  state  of  concentration, 
nothing  more. 

In  cases  of  inveterate  chalky  gout  the  behaviour  of  uric 
acid  is  well  known.  Whilst  it  is  excreted  in  a  diminished 
quantity  in  the  urine,  it  collects  in  the  gouty  deposits  ; 
and,  since  its  percentage  in  the  blood  is  never  consider- 
able, we  may  assume  that  the  local  accumulation  is  derived 
rather  from  its  retention  in  the  system  than  from  any 
excessive  production.  This  conclusion  does  not,  however, 
claim  to  be  mathematically  established  ;  much  less  can  we 
safely  extend  it  to  other  forms  and  phases  of  gout.  The 
question  is  still  whether  there  may  not  be  a  hyper-produc- 
tion of  uric  acid  in  gout,  and  many  attempts  have  recently 
been  made  to  determine,  by  indirect  methods,  whether  any 
special  form'  of  diet  is  capable  of  supplying  it  in  excess. 
The  practical  aspect  of  these  investigations  in  connection 
with  the  treatment  of  gout  is  obvious,  and  will  justify  a 
brief  reference  to  them  in  subsequent  pages. 

Much  older  than  experimental  pathology  is  the  well- 
established  clinical  observation  that  biurate  will  accumu- 
late and  form  deposits  in  the  poorly  fed,  even  in  those 
whose  dietary  includes  little  nitrogen.  In  them  Sir  A. 
Garrod  believes  that  the  accumulation  is  mainly  due,  and 


THE  ACCUMULATION  OF  URIC  ACID  95 

sometimes  entirely  due,  to  a  retention,  rather  than  to  any 
increase  in  the  production  of  uric  acid. 

Although  the  mode  of  origin  and  of  accumulation  of 
uric  acid,  and  its  vicissitudes  in  the  blood  and  in  the  juices, 
are  beyond  our  ken,  there  are  two  terminal  situations — the 
urine  and  the  gouty  deposits — in  which  it  can  be  not  only 
got  at,  but  readily  estimated.  It  may  also  be  caught 
during  its  passage  through  the  blood,  or  extracted  from 
the  tissues ;  but  here  the  determinations  are  less  certain  ; 
neither  do  we  learn  much  from  them  as  to  its  site  of 
origin. 

As  to  the  quantity  present  in  the  blood,  Levison*  remarks 
that  the  daily  amount  of  uric  acid  retained  must  be  very 
small,  or  that  the  acid  must  be  converted  in  the  blood  into 
soluble  compounds,  otherwise  tophi  would  acquire  a  much 
greater  size  than  that  which  is  observed. 

The  amount  of  the  excretion  in  gout  may  certainly  be 
taken,  on  a  broad  average,  as  not  exceeding  the  excretion 
of  a  healthy  person  ;  and  it  is  apt  to  be  either  permanently 
or  at  intervals  decidedly  less.  Camererf  arrives  at  the 
result  that  the  excretion  by  gouty  patients  does  not 
materially  differ  from  the  normal,  and  that  in  any  case  it 
is  not  increased  above  a  healthy  standard. 

Pfeiffer,J  in  his  determinations  of  the  uric  acid  excreted, 
has  reduced  the  amount  found  in  each  case  to  a  uniform 
scale  of  100  kilos  of  body  weight.  He  believes  that  the 
physiological  amount  bears  a  definite  relation  to  the  age  of 
the  individual.  In  health  he  finds  that  the  quantity 
diminishes  progressively  with  age  from  a   maximum    of 

*  Loc.  cit.,  p.  45. 

t  Deutsch.  Med.  Wochenschrift,  1891,  Nos.  10,  11  (quoted  by  Levi- 
son,  loc.  cit.,  p.  42). 

X  Berliner  Klin.  Wochetischrift,  1892,  p.  415  et  seq.;  cf.  Levison, 
loc.  cit.,  p.  42. 


96  THE  ACCUMULATION  OF  URIC  ACID 

1*250  or  i'2ii  grammes  per  day  during  the  first  decade, 
down  to  0'6i6  gramme  at  the  age  of  sixty-five,  and  even 
to  less  at  more  advanced  ages.  In  gout  which  has  not  yet 
become  chronic,  he  finds  that  rather  less  uric  acid  is 
excreted  than  corresponds  to  the  given  age.  In  advanced 
tophaceous  gout,  associated  with  arterial  disease,  albu- 
minuria, etc.,  Pfeiffer  reports  that  there  is,  on  the  con- 
trary, a  slight  increase. 


CHAPTER  XIV. 
THE    DERIVATION    OF    URIC    ACID. 

THE  'OXIDATION'  THEORY  OF  URIC  ACID. 

Since  the  observations  of  Frerichs,  and  Wohler,*  to  the 
effect  that  uric  acid  was  artificially  convertible  into  oxalic 
acid,  and  ultimately  into  urea  and  carbonic  acid,  but  that 
when  introduced  into  the  system  as  food  or  through  the 
veins,  it  was  not  excreted  as  such,  but  was  passed  out  in  the 
urine  as  urea — an  interpretation  of  the  facts  which  has  at 
a  more  recent  date  been  again  called  in  question — this  body 
was  long  regarded  as  representing  a  stage  in  the  oxidation  of 
nitrogenous  tissues  and  foods,  and  its  occasional  excess  as 
the  result  of  a  delay  at  this  stage  of  the  oxidation.  It 
was  eventually  shown  that  limitation  of  the  oxygen  supply, 
as  in  artificial  interference  with  respiration  (Senator),  or 
as  in  pathological  or  experimental  anaemia,  did  not  increase 
the  output  of  uric  acid. 

Not  less  significant  is  the  inability  of  the  oxidation 
theory  to  explain  why  the  entire  supply  of  nitrogen  is  not 
excreted  as  urea,  and  why  the  amount  of  uric  acid  excreted 
should  be  practically  constant  instead  of  being  subject  to 
accidental  variations. 

For  this  physiological  regularity,  and  for  the  excessive 
excretion    of  uric   acid   which   occurs   as    an    individual 

*  Cf.  Dr.  Vaughan  Harley,  he.  cit. 


98         STUDY  OF  THE  DERIVATION  OF  URIC  ACID 

peculiarity  in  the  subjects  of  gravel,  Sir  W.  Roberts  offers 
an  ingenious  explanation.  The  presence  in  some  of  the 
lower  animals  of  urine  consisting  almost  exclusively  of  uric 
acid,  whilst  the  urine  of  the  more  highly  evolved  is  almost 
free  from  it,  suggests  the  thought  that  evolution  may  have 
gradually  reduced  in  the  latter  the  uric  acid  department  of 
the  excretory  function  to  the  proportions  of  a  vestigial 
rudiment.  Under  the  influence  of  atavism  the  lost  function 
might  in  some  individuals  regain  some  of.  its  ancestral 
importance. 

Lastly,  it  would  be  difficult  to  explain  on  the  oxidation 
theory  the  fact  that  the  active  respiration  of  birds  and  their 
aerial  life  leaves  their  nitrogenous  excreta  in  a  relatively 
unoxidized  state. 


THE  CLINICAL  AND  EXPERIMENTAL  STUDY  OF  THE 
DERIVATION  OF  URIC  ACID. 

In  the  inquiry  as  to  the  derivation  of  uric  acid,  experi- 
ments can  only  afford  an  indirect  help :  what  we  need  to 
know  is  the  mode  of  production  of  uric  acid  in  gout.  An 
excess  of  uric  acid  induced  in  animals  or  in  man  by  artificial 
means  may  or  may  not  be  due  to  the  same  mechanism  as 
that  peculiar  to  gout.  Much  as  experimentation  has  taught 
us  as  to  the  chemical  behaviour  of  uric  acid  in  the  body, 
so  that  we  know  more  to-day  about  this  than  concerning 
gout  itself,  it  has  not  elucidated  the  derivation  of  uric 
acid.  We  cling,  therefore,  with  renewed  appreciation  to 
the  few  broad  clinical  and  physiological  facts  which  we  can 
trust  :* 

*  It  should  not  be  forgotten  that,  putting  aside  the  few  accurate 
determinations  of  the  amount  of  uric  acid  in  the  blood,  our  estimate 
of  the  amount  of  uric  acid  produced  in  the  system  is  based  upon  the 
amount  which  is  found  in  the  urine,  and  cannot  be  regarded  as  abso- 
lutely trustworthy. 


STUDY  OF  THE  DERIVATION  OF  URIC  ACID         99 

1.  In  health  the  daily  quantity  of  uric  acid  excreted  is 
small  (from  8  to  12  grains),  and  it  bears  to  the  quantity 
of  urea  an  almost  constant  proportion,  estimated  by 
Dr.  Haig  at  i  to  33,  by  others  at  i  to  40,  or  even  i  to  45. 
The  total  amounts  may  vary  ;  but  they  rise  and  fall  in  a 
fairly  even  ratio. 

2.  In  some  diseases  the  normal  output  of  uric  acid  is 
much  exceeded.  Leucocythsemia  sometimes  increases  it 
very  largely.  It  is  also  increased  in  some  of  the  diseases 
of  organs  influencing  the  constitution  of  the  blood,  and 
particularly  of  the  liver  and  of  the  lungs,  as  in  hepatic  ■ 
congestion  and  pneumonia,  and  in  gravel. 

3.  An  increase  is  sometimes  seen  also  in  the  anaemia  of 
underfed,  overworked,  or  exhausted  subjects. 

4.  A  decrease  of  the  excretion  is  observed  in  various 
other  affections,  including  chronic  gout,  diabetes,  chlorosis 
(in  some  cases),  chronic  kidney  disease,  some  forms  of 
hepatic  disease,  etc. 

5.  The  physiological  oscillations  connected  with  varia- 
tions in  the  quantity  or  in  the  kind  of  food,  or  of  muscular 
or  nervous  exertion,  usually  bear  no  comparison  in  their 
degree  with  those  due  to  disease. 

Muscular  exercise  has  a  decided  effect  in  increasing  the 
output  of  uric  acid,  and  this  may  be  due  to  the  leucocy- 
tosis  attendant  upon  excessive  muscular  exertion.  The 
excess  may,  however,  be  traced  partly  to  increased  acidity 
due  to  muscular  work  ;  and  the  possible  influence  of  the 
nervous  exhaustion  which  accompanies  muscular  fatigue 
should  not  be  lost  sight  of. 

Large  quantities  of  water  as  a  beverage  do  not  occasion 
any  increase  (Schondorff)  ;  but  alcohol  increases  the  out- 
put, perhaps  owdng  to  the  leucocytosis  which  it  induces. 

Diet  has  a  direct  influence,  the  total  excretion  being  at 
a  minimum  under  vegetable  alimentation,  greatest  under 


loo       STUDY  OF  THE  DERIVATION  OF  URIC  ACID 

an  animal  dietary,  and  at  an  intermediate  level  with  a 
mixed  diet. 

Animal  proteids,  according  to  Maruss  (quoted  by  Dr. 
Vaughan  Harley),  cause  a  larger  excretion  than  vegetable 
proteids. 

Dapper's*  recent  investigations  prove  once  more  that, 
as  previously  shown  by  Schultze,t  a  highly  proteid  diet, 
whilst  it  increases  the  absolute  amount  of  uric  acid 
excreted,  diminishes  its  relative  amount  as  compared  with 
the  total  nitrogenous  output. 

In  his  own  case.  Dapper  made  successive  observations 
on  the  amounts  excreted;  first,  during  a  period  of  abundant 
proteid  supplies  with  very  little  fat  and  carbo-hydrates  ; 
and,  subsequently,  during  a  phase  of  alimentation  poor  in 
proteids  and  rich  in  carbo-hydrates  and  fats.  During  the 
latter,  both  the  total  nitrogen  and  the  uric  acid  fell,  but 
the  uric  acid  much  less  than  the  former.  The  amounts 
are  shown  below  : 


Urea 

per  diem. 

grms. 

Uric  Acid 

per  diem. 

grms. 

Total 
Nitrogen. 

Nitrogen  as 
Uric  Acid. 

Nitrogenous  diet    21 '6 

roi 

65 

I 

Chiefly   non- nitrogenous 

diet       I2*6 

0-45 

46 

I 

Similar  determinations  were  made  in  the  person  of  a 
servant,  with  the  following  results  : 


Urea 

Uric  Acid 

Total 

Nitrogen  as 

per  diem. 

per  diem. 

Nitrogen. 

Uric  Acid. 

grms. 

grms. 

Meat  diet 

I3'46 

i-o 

43 

I 

No  meat 

9-8x7 

0-915 

32 

I 

Mixed  diet 

1475 

0788 

56 

I 

*  '  Dapper,  '  Ueber  Harnsaure  Ausscheidung  beim  Gesunden 
Menschen  unter  Verschiedenen  Ernahrungs  Verhaltnissen "  (Von 
Noorden  Beitrage).     C/.  Revue  de  M^dedne,  1894,  vol.  xiv. 

t  Arch,  de  Med.  Expir.  et  d'Anat.  Path.,  1889,  p.  871. 


STUDY  OF  THE  DERIVATION  OF  URIC  ACID       loi 

Here,  again,  therefore,  the  same  rule  appHes  :  there  is 
a  relative  increase  in  uric  acid  with  the  vegetable  diet, 
although  the  total  nitrogen  sinks.  The  figures  would  seem 
to  show  that  with  a  mixed  diet  the  amount  of  uric  acid  is 
least,  both  absolutely  and  relatively,  although  the  urea 
may  be  abundant. 

These  facts  are  in  contradiction  with  Pfeiffer's  idea  that 
there  exists  a  settled  proportion  between  the  body-weight 
and  the  amount  of  uric  acid  excreted.  Dapper  found  that 
for  100  kilos,  of  body-weight  the  amounts  of  uric  acid 
varied  between  0*57  and  1*44. 

Piperazine  was  tried  in  the  second  sets  of  experiments, 
4  grammes  being  administered  daily  for  three  days.  This 
took  but  slight  effect  on  the  excretions,  the  proportion 
being  altered  from  i — 43  to  i — 45. 

THE  DERIVATION  OF  URIC  ACID  FROM  NUCLEIN. 

The  work  of  Horbaczewski,  of  Kossel  and  of  others,  has 
opened  up  a  fresh  field  for  the  study  of  the  origins  of  uric 
acid.  Horbaczewski*  found  that  uric  acid  might  be  derived 
from  the  decomposition  of  tissues,  and  with  particular 
facility  from  that  of  the  spleen.  This  discovery  was  a 
confirmation  of  a  view  conceived  long  ago  by  Parkes,  and 
entertained  since  then  by  others. 

The  method  adopted  was  the  following :  fresh  splenic 
pulp  was  digested  for  8  hours  at  50°  C.  with  8  to  10  parts 
of  water.  When  in  the  early  stage  of  putrefaction  the 
mass  gives  a  filtrate  which,  after  treatment  with  subacetate 
of  lead  and  after  sterilization,  contains  neither  uric  acid 
nor  xanthine  bases  ;  but,  if  now  boiled,  it  immediately  gives 

*  J.  Horbaczewski,  '  Beitrage  zur  Kenntniss  der  Bildung  der  Harn- 
saure  und  der  Xanthin  basen  '  {Monatshefte  filr  Chemie,  xii.,  pp.  221- 
276). 


I02     THE  DERIVATION  OF  URIC  ACID  FROM  NUCLEIN 

xanthine  and  hypoxanthine,  but  remains  free  from  adenine 
or  guanine. 

If,  instead  of  being  boiled,  the  splenic  pulp  is  allowed  to 
stand  (at  40°  C.)  in  contact  with  some  arterialized  blood 
or  with  oxygen -water,  or  if  it  be  merely  exposed  to  an 
atmosphere  of  oxygen,  it  will  ultimately  be  found  to  con- 
tain uric  acid  in  the  proportion  of  0"0025  grammes  for 
each  gramme  of  pulp. 

On  the  other  hand,  by  artificial  digestion  of  the  spleen, 
pure  nuclein  may  be  obtained,  from  which,  by  allowing  it 
to  stand  at  40°  C.  in  contact  with  blood,  uric  acid  will 
split  off. 

These  observations  were  not  limited  to  splenic  pulp,  but 
Horbaczewski  found  that  a  similar  supply  could  be  derived 
from  the  mucous  membrane  of  the  small  intestine,  from  red 
marrow,  from  the  thymus,  from  muscle,  from  the  salivary 
gland,  the  gastric  and  intestinal  mucous  membrane,  the 
pancreas,  the  liver,  the  lung,  the  brain,  the  kidney,  the 
skin,  the  tendons,  the  cervical  ligaments,  the  cartilages  of 
the  ear,  etc.,  and  from  pus.  They  all  yield  xanthine,  as 
an  indication  that  uric  acid  could  be  likewise  derived. 

From  these  observations  Horbaczewski  argues  that  as 
the  organs  do  not  change  sufficiently  rapidly  to  account 
for  the  output  of  uric  acid,  the  leucocytes,  which  are 
abundantly  contained  in  the  spleen,  and  also  present 
everywhere  in  the  tissues,  must  be  the  source  of  the 
nuclein.  If  so,  uric  acid  would  vary  in  its  production 
according  to  the  variations  observed  or  induced  in  the 
aggregate  number  of  leucocytes. 

Experimentally,  it  was  found  that  quinine  and  atropine, 
which  both  diminished  the  number  of  leucocytes,  also 
depressed  the  excretion  of  uric  acid,  and  that  pilocarpine 
had  the  opposite  effect  on  both ;  antifebrine  and  phena- 
cetine,  however,  increase  the  one  while  decreasing  the  other. 


THE  DERIVATION  OF  URIC  ACID  FROM  NUCLEIN     103 

Returning  now  to  nuclein,  Horbaczewski  found  that  its 
injection  into  the  veins  largely  increased  the  uric  acid  out- 
put. This  fact,  however,  could  not  lead  to  any  final  con- 
clusion, inasmuch  as  the  same  substance,  when  injected, 
increased  the  leucocytes  as  well ;  and  the  question  remains 
undecided  whether  the  increased  production  of  uric  acid 
is  the  result  of  the  injection  and  arterialization  of  so  much 
nuclein,  or  of  the  proliferation  of  living  leucocytes  to 
which  the  injection  may  have  given  rise. 

Stadthagen  appears  to  have  obtained  in  dogs  the  opposite 
result — decrease  of  uric  acid,  increase  of  urea.  Conflicting 
results  have  also  been  reported  by  various  observers  in 
connection  with  the  direct  ingestion  of  uric  acid. 

Our  ideas  as  to  the  fate  of  any  additional  quantities  of 
uric  acid  introduced  into  the  economy  thus  remain  in 
suspense.  In  leucocythaemia  the  vast  increase  in  the 
number  of  leucocytes  should,  according  to  the  nuclein 
theory,  go  hand  in  hand  with  an  increase  in  the  uric  acid. 
The  results  obtained  long  ago  by  Bartels,  as  well  as  those 
of  more  recent  observers  (Schultze  and  Ebstein),  fully 
confirm  that  surmise. 

Fleischer  and  Penzoldt  (quoted  by  Dr.  Vaughan  Harley) 
attempted  a  further  proof  by  feeding  a  leucocythaemic  and 
a  healthy  person  on  the  same  diet.  The  same  weight  of 
urea  was  produced  in  both  cases  from  the  proteid  supply ; 
but,  over  and  above  this  nitrogenous  output,  the  morbid 
urine  contained  double  as  much  uric  acid  as  the  healthy. 
.  According  to  these  views,  the  conditions  leading  to  an 
increase  of  uric  acid  would  be  practically  those  leading  to 
a  leucocytosis. 

It  had  long  been  known  that  in  health  a  varying  degree 
of  leucocytosis  follows  each  important  meal,  especially  if 
much  proteid  be  taken.     Maruss,*  starting  from  this  obser- 
*  Quoted  by  Dr.  Vaughan  Harley,  loc.  tzV.,  p.  637. 


I04     THE  DERIVATION  OF  URIC  ACID  FROM  NUCLEIN 

vation,  determined  the  amount  of  uric  acid  excreted  at 
different  periods,  and  found  that,  whereas  urea  excretion 
was  slow  to  set  in  and  slow  to  attain  its  maximum  (as  late 
as  nine  hours  after  the  meal),  the  uric  acid  excretion  (which 
was  greater  after  animal  than  after  vegetable  diet)  began 
early,  and  reached  its  maximum  as  soon  as  two  to  five 
hours  after  the  meal,  having  by  this  time  doubled  or  trebled 
its  previous  amount ;  after  this,  it  gradually  sank  till  the 
thirteenth  hour  of  fasting,  when  it  remained  constant. 

The  results  obtained  by  Chittenden  and  by  Cameron,  in 
animals  and  in  man,*  also  show  a  parallel  increase  in  the 
leucocytes  and  in  the  amount  of  uric  acid  excreted. 

The  same  result  has  been  found  to  follow  the  ingestion 
of  pilocarpine  and  of  phosphorus,  whilst  quinine  and  arsenic 
have  the  opposite  effect. 

The  greater  proportion  of  white  cells  normally  present 
in  the  blood  of  children,  whose  excretion  of  uric  acid  is 
decidedly  greater  in  proportion  to  their  body-weight  than 
that  of  the  adult,  is  an  important  physiological  fact  in  the 
same  direction. 

In  simple  ancemia  the  excretion  is  not  increased,  leucocytes 
not  being  present  in  excess.  This  adds  weight  to  the  in- 
ference derived  from  leucocythsemia,  where  the  increase 
of  uric  acid  is  regarded  as  due  to  the  vast  increase  in 
leucocytes.  Other  diseases,  such  as  pneumonia,  which 
cause  proliferation  of  leucoc3'tes,  likewise  lead  to  increased 
uric  acid  excretion. 

Levison,*!"  who  agrees  with  Garrod  and  Roberts  in  re- 
garding the  accumulation  of  uric  acid  as  due  to  deficient 
excretion  rather  than  to  hyperproduction,  does  not  accept 
Horbaczewski's  views  as  in  any  way  applicable  to  gout. 
He  states  that  gout  is  not  attended  with  any  leucocytosis, 

*  Quoted  by  Dr.  Vaughan  Harley,  loc.  ciL,  p.  ^138. 
t  Zeitsch.  fiir  Klin.  Med..,  1894,  xxvi. 


THE  SEAT  OF  PRODUCTION  OF  URIC  ACID        105 

and  that  therefore  the  nuclein  of  leucocytes  does  not  enter 
into  account.  On  the  other  hand,  the  uric  acid  excess  in 
gout  is  not  so  great  as  in  pneumonia  and  leucocythsemia. 
He  seeks  to  explain  this  difficulty  by  the  fact,  demonstrated 
by  Roberts,  that  the  quadriurates  require  to  be  held  in 
solution  for  some  time  to  allow  the  biurate  to  be  formed 
and  deposited  ;  healthy  kidneys  would  eliminate  the  excess 
of  urate  too  quickly  for  this. 

THE  SEAT  OF  PRODUCTION  OF  URIC  ACID. 

The  place  of  origin  of  uric  acid  has  been  variously  held 
to  be  :  (i)  the  kidney  ;  (2)  the  liver  ;  (3)  the  spleen  ;  (4)  the 
tissues  in  general,  and  in  particular  the  connective  tissues  ; 
(5)  the  leucoc3-tes. 

Zalesky's  well-known  experiments  led  him  to  conclude 
that  the  kidneys  were  the  site  of  formation  of  uric  acid. 
For,  when  the  ureters  were  ligatured,  no  diminution  was 
observed  in  the  amount  of  uric  acid,  but  merely  a  change 
in-  the  locality  of  its  storage.  Being  prevented  from  de- 
scending into  its  normal  reservoirs,  it  ascended  above  the 
kidneys,  which  remained  free  except  in  their  pyramids, 
where  the  tubes  were  blocked  with  it,  and  was  deposited 
in  the  lymphatics  and  all  the  serous  membranes  except 
the  meninges,  in  some  of  the  small  bronchi,  in  the  heart- 
muscle,  in  the  capsule  of  the  liver,  but  not  in  the  hepatic 
substance,  and  in  the  cartilages  and  the  articular  mem- 
branes and  cavities.  Specially  noteworthy  was  its  absence 
from  the  voluntary  muscles  and  from  the  bloodvessels, 
although  the  blood,  the  bile,  and  other  juices  were  freely 
charged  with  it,  and  its  presence  in  the  mucous  membrane 
of  the  stomach  and  of  the  intestine. 

On  the  other  hand,  when  the  kidneys  of  serpents  were 
excised,  although  the  period  of  survival  was  the  same  as 


lo6        THE  SEAT  OF  PRODUCTION  OR  URIC  Acm 

in  the  previous  experiments  (about  twelve  days),  no  uric 
acid  was  found  to  accumulate  in  the  tissues. 
.  Zalesky's  conclusion  from  these  experiments  has  been 
called  in  question,  at  any  rate  they  cannot  be  applied  in 
the  absence  of  further  proof  to  the  case  of  mammalia  and 
of  man.  In  opposition  to  Zalesky,  Schroeder  has  shown 
that  in  birds  the  production  of  uric  acid  is  not  limited  to 
the  kidney,  but  occurs  in  various  tissues. 

The  view  propounded  by  H.  Ranke  that  the  spleen  takes 
a  leading  part  in  the  formation  of  uric  acid  is  supported  by 
the  fact  that  splenic  enlargement  in  leucocythsemia  is  asso- 
ciated with  an  increased  excretion  of  uric  acid,  and  that 
quinine  diminishes  the  excretion.  It  is  important  to  note 
that  the  same  increase  is  observed  in  lymphatic  leuco- 
cythsemia. 

Dr.  Haig  holds  that  uric  acid  is  largely  stored  by  the 
spleen  under  those  circumstances  which  preclude  its  ready 
solubility  and  its  ready  circulation  in  the  blood. 

Professor  Latham,  as  elsewhere  stated,  ascribes  a  share 
in  the  formation  of  uric  acid  to  the  kidney. 

The  liver  has  long  been  suspected  of  being  the  main  seat 
of  production,  and  many  arguments  have  been  adduced  in 
support  of  this  view.  The  experimental  ligature  or  extir- 
pation of  the  renal  organs  showed  that  many  tissues  share 
with  the  kidney  the  capability  of  forming  uric  acid,  but 
that  the  liver  possesses  this  power  in  a  high  degree. 
Meissner,*  in  1868,  determined  in  birds  that  the  amount 
of  uric  acid  was  always  greater  in  the  liver  than  in  the 
blood. 

Experimenting  on  geese,  Minkowski")*  extirpated  the  liver, 
and  during  the  six  to  twenty  hours  of  their  survival,  found 
that  3  to  6  per  cent,  only  of  the  nitrogen  was  then  excreted 

*  Quoted  by  Dr.  Vaughan  Harley,  /oc.  «/.,  p.  638.  f  /did. 


THE  SEAT  OF  PRODUCTION  OF  URIC  ACID         107 

as  uric  acid,  instead  of  60  to  70  per  cent,  as  in  health. 
The  nitrogen  appeared  to  pass  out  in  the  shape  of  ammonia 
to  the  extent  of  50  to  60  per  cent.,  instead  of  g  to  18  per- 
cent, only  during  health. 

Other  important  experiments,  however,  do  not  point  to 
the  liver  as  the  chief  producer. 

Hahn,  Massen,  Nenchi,  and  Pawlow,*  ingeniously 
diverted  the  portal  circulation  of  dogs  into  the  inferior 
vena  cava,  thus  shutting  off  the  liver  from  the  general  cir- 
culation. The  result  of  this  experiment,  which  did  not 
constitute  so  severe  a  measure,  was  that  the  uric  acid  out- 
put was  greatly  increased,  although  less  urea  was  passed, 
the  bulk  of  the  nitrogen  being  eliminated  as  ammonium 
carbamate. 

Nevertheless,  the  old  view  that  the  liver  is  a  chief  seat 
of  production  still  holds  its  own,  and  clinical  observation 
lends  to  it  much  probability,  although  the  synthetical  pre- 
paration of  uric  acid  by  Horbaczewski,  and  subsequently 
by  Professor  Latham,  has  not  availed,  as  might  have  been 
hoped,  to  solve  the  question  definitely. 

We  are  led  by  these  uncertainties  to  look  more  closely 
into  the  processes  of  assimilation.  There  is  a  yet  earlier 
function  than  that  of  the  digestive  glands,  performed  by 
elements  possessed  of  multifarious  activities,  and  which 
are  ubiquitous.  The  leucocytes,  which  are  in  respect  of 
their  locomotion,  and  perhaps  in  respect  of  their  intra- 
cellular movements,  among  the  most  active  constituents  of 
the  body,  stand  in  a  close  relation  to  the  process  of  alimen- 
tation. It  is  well  known  that  they  undergo  a  remarkable 
multiplication  after  meals  and  are  obviously  concerned 
with  the  work  of  elaboration  of  food  as  well  as  with  that  of 
purification  of  the  blood.     They  are  in  great  measure  the 

*. Quoted  by  Vaughan  Harley,  loc.  cit.,  p.  638. 


io8        THE  SEAT  OF  PRODUCTION  OF  URIC  ACID 


food  carriers  ;  and  in  the  special  form  of  overfeeding  which 
ultimately  leads  to  gout,  they  must  be  the  first  to  experi- 
ence the  saturation  with  nitrogenous  surplus  which  over- 
takes all  the  fixed  elements  of  tissue.  If  the  effect  on  the 
latter  is  a  diminished  vitality,  a  lessened  resistance,  and 
a  degeneracy,  we  may  expect  to  find  the  same  tendency 
carried  out  in  them  to  a  much  higher  degree,  and  perhaps 
resulting  in  earlier  decay  and  destruction. 

To  what  extent  they  may  have  a  share  in  the  manipula- 
tion of  the  excess  of  uric  acid  circulating  in  the  blood  is 
beyond  the  range  of  speculation.  In  their  capacity  of 
scavengers  they  are  hitherto  known  to  deal  only  with 
solid  particles.  This,  of  course,  need  not  exclude  an 
absorptive  or  selective  power  for  substances  in  a  state  of 
solution  ;  but  of  this  we  know  nothing. 

On  the  other  hand,  they  stand  in  a  peculiar  relation  to 
uric  acid,  which  has  been  pointed  out  by  Horbaczewski. 
Nuclein,  of  which  their  nucleoli  consist,  can  be  made  to 
yield  uric  acid,  and  in  this  we  possess  a  source  of  uric  acid 
the  supply  from  which  might  conceivably  vary  with  the 
rate  of  cell  reproduction  and  decay.  The  life  history  of 
the  leucocytes  might  in  this  way  be  intimately  connected 
with  oscillations  in  the  amount  of  uric  acid  set  free  in  the 
blood  or  withheld  from  it. 

These  speculations,  though  they  are  as  yet  imperfectly 
supported  by  observation,  may  serve  to  illustrate  the  idea 
of  the  bio-chemistry  of  uric  acid  as  opposed  to  the  purely 
chemical  description  hitherto  given.  They  afford  us 
insight  into  the  vital  or  dynamic  aspect  of  the  problem, 
which  the  present  theories,  and  in  particular  the  theory  of 
renal  inadequacy  in  gout,  have  perhaps  not  sufficiently 
taken  into  account.  Brown  Sequard's  discovery  of  the 
process  of  internal  secretion  and  the  discovery  of  chemotaxis 
and    of    phagocytosis    suggest    novel    directions    for    our 


THE  SEAT  OF  PRODUCTION  OF  URIC  ACID        109 

theories  and  experiments.  We  now  recognise  in  cells, 
and  particularly  in  leucocytes,  activities  far  beyond  those 
of  simple  imbibition  and  assimilation.  Uric  acid  may 
come  within  these  spheres  of  influence.  It  is  now  con- 
ceivable that  the  non-excretion  at  the  kidney  may  be  due 
less  to  a  renal  block  than  to  some  more  active  retention, 
for  which  cellular  attractions  may  be  responsible. 


IV. 
THE  MORBID  ANATOMY  OF  GOUT. 


CHAPTER  XV. 

THE  ARTICULAR  LESIONS  IN  GOUT. 

In  spite  of  the  variety  of  its  clinical  symptoms,  general 
or  constihitional  gout  cannot  hitherto  claim  to  possess  a 
morbid  anatomy  of  its  own.  The  visceral  lesions  often 
associated  with  it  occur  yet  more  frequently  in  its  absence, 
and  are  not  specifically  gouty.  Sodium  biurate  and  the 
consequences  of  its  deposition  are  the  only  specific  changes 
to  be  found  under  the  scalpel,  and  they  belong  to  local 
gout,  the  morbid  anatomy  of  which  should  be  dealt  with 
as  a  strictly  separate  study.  The  whole  subject  is  thus 
divided  into  two  sections  :  (i)  the  affections  of  the  joints, 
cartilages,  bones,  and  fibrous  tissues  connected  with  a 
local  deposition  of  the  biurate,  including  also  the  deposits 
found  rarely  in  other  situations ;  and  (2)  the  general  changes 
connected  with  constitutional  gout  and  gouty  cachexia,  and 
^any  visceral  lesions  incidental  to  gout. 

(i)  There  is  most  to  describe  in  the  anatomy  of  chronic 
deforming  gout,  and  this  was  long  ago  described  by  the 
ancients,  even  to  the  concretions  or  pultaceous  accumula- 
tions found  in  the  cavities  of  the  joint.  The  changes  in 
the    earlier   cases,  or   in    inveterate   gout  without    much 


THE  ARTICULAR  LESIONS  IN  GOUT  lit 

.deformit}^  M^ere  not  accurately  known  until  modern  times. 
We  owe  to  Garrod  the  demonstration  in  them  of  the 
presence  of  sodium  biurate  in  the  cartilages  and  other 
joint  structures.  The  uratic  lesion  is  therefore  regarded 
as  present  both  in  the  acute  and  in  the  chronic  stages, 
and  the  question  arises,  Is  it  ever  absent  where  gouty 
symptoms  occur  ? 

In  the  joints  biurate  is  deposited  within  the  cartilage  in 
the  shape  of  extremely  fine  needles,  and  may  also  be 
found  external  to  it  in  the  synovia.  Outside  the  joints  it 
is  deposited  in  the  surrounding  fibrous  structures  and 
tendons.  Destructive  changes  may  gradually  occur  in  the 
same  joints,  and,  if  progressive,  may  lead  to  considerable 
deformit}',  and  ank3dosis  ;  but  outside  the  joints  the  accu- 
mulations of  uric  acid  may  be  extensive  without  inducing 
necrosis.  These  outer  deposits,  disfiguring  and  to  a  certain 
extent  crippling,  although  usually  painless,  are  known  as 
tophi.  The  skin  over  them  may  be  so  much  atrophied 
and  so  greatly  stretched  as  to  ultimately  ulcerate,  when 
complications  may  arise. 

(2)  Visceral  deposits  of  biurate  have  been  found  quite 
exceptionall}'.  The  only  visceral  changes  occurring  with 
great  frequency  are  degenerative  lesions  in  the  kidney 
and  in  the  bloodvessels;  but  renal  cirrhosis  and  arterial 
atheroma  are  both  commonly  present  in  other  conditions 
quite  apart  from  gout,  and  are  then,  as  in  gout,  apt  to 
lead  to  cardiac  disease. 


THE  ARTICULAR  STRUCTURES. 

The  small  joints  are  first  involved,  beginning  with  the 
toe,  then  the  metacarpo-  and  metatarso-phalangeal  joints, 
the  tarsus  and  the  carpus,  and,  lastly,  the  large  joints. 
In  an  unusual  case  mentioned  by  Garrod  this  rule  was 


112  CARTILAGE 


departed  from,  and  the  hand  was  not  involved,  though  the 
knee  was  affected.  In  general,  the  more  attacks  there 
have  been,  the  more  widely  will  the  implication  of  the 
joints  extend.  This  suggests  the  inquiry :  Could  gout 
itself  be  checked  as  a  constitutional  ailment  by  checking 
the  local  attacks  ?  That  this  might  be  the  case  has  been 
often  suspected,  and  Garrod's  theory  almost  directly  leads 
to  this  conclusion. 

CARTILAGE. 

Of  all  the  joint  structures,  the  cartilages  are  the  first  to 
exhibit  the  characteristic  uratic  deposit,  either  as  a  fine 
white  superficial  incrustation,  or  as  a  diffuse  infiltration  of 
the  matrix  and  of  the  cells,  and  occasionally  as  a  deposit  in 
the  deeper  layers.  Anatomical  and  chemical  explanations 
have  been  offered  for  the  special  liability  of  cartilage. 
The  chemical  theories  need  not  be  mentioned  again.  The 
anatomical  and  physiological  explanations  are  based  upon 
the  extravascular  nutrition  of  the  tissue,  and  its  proneness 
to  suffer  from  the  effects  of  pressure  or  contusions. 

The  cartilage  first  shows  stains,  striae  or  dull  patches,  and, 
lastly,  the  characteristic  deposit  in  its  thickness.  At  first 
the  smoothness  of  the  surface  is  not  interfered  with,  though 
a  fine  deposit  of  biurate  may  be  visible,  showing  that  the 
earliest  deposit  need  not  be  superficial.  Later,  unevenness 
or  pitting  may  alternate  with  smoother  patches ;  but  the 
destruction  is  progressive,  and  ultimately  the  cartilage 
may  disappear  and  the  joint  become  filled  with  a  plaster- 
like mass,  and  its  structures  disorganized. 

Whilst  atrophic  changes  and  erosion  are  proceeding  in 
the  articular  cartilages,  hypertrophic  outgrowths  develop 
at  their  free  margins.  The  *  lipping '  observed  in  so  high 
a  degree  in  rheumatoid  arthritis  is  a  feature  common  to 
all  forms  of  chronic  arthritis,  and  is  also  found  in  gout. 


CARTILAGE  113 


According  to  Dr.  Wynne,*  the  marginal  outgrowths  in  gout 
are  true  exostoses,  and  not,  as  previously  thought,  ecchon- 
droses,  as  in  rheumatoid  arthritis. 

As  to  the  exact  localization  of  the  biurate,  Budd  believed 
that  the  early  white  striae  were  central,  not  peripheral ; 
and  it  was  considered  that  the  vascular  synovial  fringes 
and  the  insertion  of  ligaments,  being  better  supplied  with 
vessels  and  possessing  a  higher  vitality,  were  less  obnoxious 
to  the  deposition. f  According  to  Rendu,  these  situations 
are  not  exempt,  and,  indeed,  sometimes  they  present 
peripheral  fibrous  bundles  obviously  connected  with  a 
process  of  peripheral  irritative  overgrowth.  This  author 
regards  the  deposit  as  probably  a  simple  interstitial  incrus- 
tation encouraged  by  weakness  of  circulation,  as  in  senile 
calcification. 

Sir  Dyce  Duckworth  has  arrived  at  the  following  con- 
clusions -.l  '  There  is  no  special  microscopical  condition  of 
cartilage  peculiar  to  gouty  deposit ;  the  common  site  of 
deposit  is  at  the  free  surfaces ;  but  it  may  occur  at  any 
point,  and  the  cells  are  not  foci  of  deposition.' 

Anatomical  investigations  have  thus  led  him  to  the 
same  results,  in  connection  with  the  superficial  deposits, 
as  those  derived  by  Sir  W.  Roberts  from  a  chemical  study 
of  the  question.  He  was  not  able  to  identify  the  necrotic 
changes  described  by  Ebstein  ;  though,  after  washing  out 
the  deposit,  a  granular  appearance  was  found  in  the 
cartilage,  actual  destruction  being  present  only  where  the 
deposits  were  very  abundant.  The  superficial  zone  of 
the  cartilage  is  the  first  to  disappear.  The  more  advanced 
lesions,  such  as  proliferations  of  the  cells,  fibrillations  of 
the  matrix,  and  erosions  which  may  expose  the  bone,  are 
sometimes  seen,  independently  of  gout,  as  senile  changes. 

*  Cf.  Duckworth,  he.  «V.,  pp.  76,  77. 

t  Cf.  Roberts,  loc.  cit.  %  Loc.  cit.,  p.  67. 


114  CARTILAGE 


On  the  other  hand,  uratic  incrustation  of  the  cartilage  is 
sometimes  observed  where  declared  gout  has  not  existed 
during  life.* 

Ebstein  contends  that  crystallization  of  the  biurate  in 
the  cartilages  is  always  secondary  to  some  previous  dis- 
integration of  their  tissue.  The  same  view  had  been 
stated,  though  less  categorically,  by  various  observers. 
Parkes  had  conceived  the  idea  that  uric  acid  was  generated 
locally  from  the  degenerating  tissue.  Laycock  also 
favoured  this  view. 

Ebstein's  views  are  to  a  certain  extent  supported  by 
such  opinions  as  that  of  Bowlby,  viz.,  that  urates  are 
never  deposited  except  in  damaged  cartilage,  and  that 
some  of  the  salt  may  arise  from  disintegration  of  the 
cartilage ;  and  of  Cantani,  who  supposes  preliminary  dis- 
turbance in  nutrition  of  the  joint,  and  thinks  that,  as  set 
forth  by  Robin,-]-  gelatinous  structures  may  suffer  transfor- 
mation into  uric  acid.j 

BONE. 

Within  the  bones  changes  are  not  usually  present  at 
first.  The  proliferative  osteitis  of  the  dense  bony  layers, 
and  the  associated  rarefying  osteitis  of  the  spongy  parts, 
to  which  the  enlargement  of  the  bone-ends  is  due,  are,  in 
the  great  majority  of  instances,  secondary  inflammations. 
Cruveilhier  had  described  spontaneous  deposition  of  urates 
in  bones,  and  Rendu§  mentions  a  case  related  by  Fereol.|| 
Garrod,  however,1I  does  not  accept  its  independent  impli- 
cation, but  merely  an  extension  within  it  of  the  deposition 
beginning  in  the  joint.     But,  according  to  Duckworth, 

*  Cf.  Duckworth,  /oc.  «/.,  p.  64. 

t  '  Dictionnaire  de  Mddecine,'  1865. 

X  Cf.  Duckworth,  loc.  cit.,  p.  64.  §  Loc.  cit.,  p.  22. 

II  '  Union  Mdd.,  1869,  p.  289.  \  Loc.  cit.,  p.  210. 

**  Loc.  cit.,  p.  70. 


**■ 


BONE  115 

uratic  deposits  have  been  repeatedly  observed  within  the 
bone,  independently  of  any  affection  of  its  cartilaginous 
covering. 

In  cases  of  long  standing,  degenerative  changes  occur  in 
the  bony  substance,  perhaps  in  connection  with  disuse, 
the  spongy  tissue  becoming  rarefied  and  greasy,  and  the 
marrow  cells  fatty.  More  definite  and  truly  distinctive 
are  the  early  and  the  late  changes  observed  in  the  joint- 
ends  of  the  long  bones.  Heberden's  nodes  are  relatively 
early  manifestations  in  a  certain  class  of  cases  in  which 
gout  pursues  a  slow  and  almost  latent  course,  and  may 
never  culminate  in  an  acute  attack.  Their  presence  is  a 
help  to  diagnosis ;  but,  inasmuch  as  they  may  occur  in 
other  associations — indeed,  Heberden  himself  denied  that 
they  had  any  connection  with  gout — they  should  never  be 
regarded  as  conclusive,  but  considered  in  conjunction  with 
other  indications. 

The  late  changes  are  the  lipping  of  the  rim,  and  the  not 
infrequent  synostosis  of  the  articular  surfaces  of  the  bones. 
The  bony  nature  of  the  marginal  outgrowths,  the  bony 
ankylosis,  and  the  absence  of  the  eburnation  special  to 
osteo-arthritis,  are  characteristic  skeletal  features  of  gout, 
and  enable  us  to  identify,  the  disease  from  the  mere 
inspection  of  bones  long  buried. 

The  occurrence  of  total  ankylosis  is  facilitated  by  the 
incrustation  and  stiffening  of  the  ligaments,  conditions 
which  yet  more  often  lead  to  a  spurious  ankylosis. 

THE  JOINTS. 

After  the  cartilages,  the  synovial  membrane,  the  liga- 
ments and  tendons,  and  the  connective  tissue  become 
affected,  and  the  bone  may  also  be  the  seat  of  deposition, 
though  this  is  not  the  rule. 


ii6  THE  JOINTS 

The  process  of  deposition  can  remain  latent  only  when 
limited  to  the  articular  cartilage.  On  the  other  hand,  the 
cartilages  may  show  after  death,  in  cases  with  an  un- 
doubted gouty  history,  absence  of  biurate,  but  a  pitted 
condition  indicative  of  its  former  precipitation.  This  con- 
dition is  distinct  from  the  abrasions  and  erosions  not 
uncommon  in  the  cartilages  of  the  aged,  but  thought  to  be 
more  frequent  in  gouty  than  in  other  subjects.  The 
general  absence  of  tophi  and  of  external  deposits  where 
the  cartilages  are  extensively  infiltrated  has  been  pointed 
out  by  Dr.  Norman  Moore,*  as  well  as  the  occasional 
absence  of  intra-articular  deposits  in  nodular  joints,  the 
ligaments  of  which  and  the  adjacent  tendons  may  contain 
biurate  crystals.  Some  of  the  large  joints,  especially  the 
knees  and  ankles,  are  prone  to  gouty  arthritis  ;  others,  and 
particularly  the  hip  and  the  shoulder,  as  long  ago  observed 
by  Garrod,  are  remarkably  exempt.  We  owe  to  Dr. 
Norman  Mooref  an  elaborate  analysis  of  the  relative 
liability  of  the  various  joints  in  a  series  of  eighty  cases 
examined  after  death : 

(i)  Whenever  urates  are  present  in  any  one  joint, 
degenerative  changes  usually  are  found  in  the  same  joint 
or  in  other  joints  of  the  same  body.  (2)  Deposits  of  urate 
of  sodium  resemble  other  degenerative  changes  in  being 
usually  more  or  less  symmetrical.  (3)  The  deposit  is  more 
often  found  in  the  joints  of  the  legs  than  of  the  arms. 
(4)  Nearly  all  the  joints  of  the  lower  limb  may  be  affected, 
and  none  of  the  upper.  (5)  The  metatarso-phalangeal 
joint  of  the  great  toe  more  often  presents  the  deposit  than 
the  phalangeal.  (6)  However  abundant  in  and  below  the 
knees,  a  deposit  is  rare  in  the  hip-joint.  (7)  The  great 
toes  and  knees  often  present  a  deposit  when  the  ankles  are 

*  Cf.  Duckworth,  loc.  cit.,  p.  69. 

t  '  St.  Bartholomew's  Hospital  Reports,'  vol.  xxiii.,  1887. 


THE  JOINTS  117 

free  from  it  ;  but  the  ankles  never  present  it  if  it  be  absent 
from  the  toes  and  knees.  (8)  When  present  in  the  ankle, 
the  deposits  usually  also  affect  the  ligaments  of  the  foot, 
(g)  A  deposit  in  the  wrist  is  accompanied  with  one  in  the 
elbow-joint.  (10)  The  sterno-clavicular  jo-int  rarely  shows 
deposit.  (11)  The  articulation  of  the  larynx  rarely  presents 
any  deposit. 

Articular  cartilages  may  be  heavily  affected  with  deposit 
without  any  external  deposition,  such  as  tophi.  Urates 
are  sometimes  not  found  in  the  interior  of  joints  which 
have  become  nodular,  though  specks  of  deposit  may  be 
found  in  their  ligaments  and  adjacent  tendons.  The 
immunity  of  the  hip-joint  and  of  the  shoulder-joint  are 
specially  to  be  noticed. 

The  deformities  of  the  hands  in  chronic  gouty  arthritis, 
apart  from  tophi  and  nodular  enlargements,  are  not 
essentially  different  from  those  described  by  Charcot  in 
rheumatic  cases.  They  are  made  up  of  a  lateral  deflection 
of  the  fingers  towards  the  ulna,  and  of  a  flexion  of  the 
proximal  phalanx  towards  the  palm,  with  or  without  a  like 
flexion  of  the  terminal  phalanx,  the  middle  phalanx 
remaining  in  extension.  The  bending  of  the  fingers  is 
satisfactorily  explained  in  connection  with  the  contraction 
of  the  palmar  fascia,  and  with  the  uneven  antagonism  of 
the  flexor  and  extensor  muscles.  Among  the  factors  of 
deflection,  attention  may  be  drawn  to  the  influence,  in  the 
act  of  prehension,  of  the  pressure  of  the  thumb,  which  is 
usually  not  affected,  on  the  fingers,  and  especially  to  the 
considerable  and  constantly  recurring  pressure  thrown 
upon  the  radial  border  of  the  index  in  rising  from  the 
recumbent  or  sitting  posture. 

In  the  ligaments  the  deposits  take  various  forms,  dotted, 
streaky,  or  diffused.  Even  in  the  synovial  fringe  deposits 
may  occur,  viz.,  in  its  subepithelial  and  subserous  layers. 


ii8  THE  JOINTS 


Rendu  concludes  that  in  all  situations  they  tend  to  be 
localized,  as  in  the  case  of  the  tophus,  in  the  depth  of 
parts. 

The  synovia  may  be  clear,  as  in  the  earliest  cases,  or, 
more  rarely,  milky ;  or  it  may  be  coloured  with  blood. 
Its  reaction  is  neutral  or  alkaline,  but  occasionally,  as 
observed  by  Garrod  (Observation  7),  it  may  be  acid. 
Where,  as  so  often  occurs,  a  biurate  is  precipitated  in  the 
synovial  fluid,  its  origin  may  be  attributed  to  two  sources, 
the  synovia  or  the  incrustations. 

Although  relatively  passive,  cartilages  and  fibrous  tissue 
ultimately  react  to  the  irritation,  and  a  subinflammation 
arises.  A  double  change  takes  place  in  the  cartilage — a 
new  formation,  or  ecchondrosis  (Virchow),  and  a  destruc- 
tive ulceration  of  the  surface  by  attrition.  As  a  conse- 
quence of  the  latter  change,  severe  destructive  lesions 
arise  in  the  larger  joints,  knees  and  ankles.  In  the  smaller 
joints  total  incrustation  may  occur,  and  there  may  remain 
practically  no  cartilage,  no  synovia,  merely  a  mass  of 
plaster-like  deposit  extending  from  bone  to  bone  and  from 
ligament  to  ligament. 


THE  PERI-ARTICULAR  TISSUES,  LIGAMENTS,  FIBROUS 
TISSUES,  TENDONS,  AND  BURSM. 

Next  to  the  cartilages  themselves,  the  ligaments  and  the 
fibrous  tissue  protecting  the  joints,  the  synovial  sheaths  of 
the  tendons,  and  the  neighbouring  bursse,  are  specially 
prone  to  the  deposits  ;  and  we  might  therefore  expect  a 
special  liability  to  gouty  lesions  in  joints  (as  in  the  hands 
and  feet)  possessing  complicated  ligaments  and  an  abundant 
fibrous  environment,  with  many  tendons. 

Peri-articular  deposits  in  the  fibrous  tissue  adjoining  the 
articulations  are  often  of  considerable  thickness.     In  well- 


THE  PERI-ARTICULAR  TISSUES,  ETC.  iig 

marked  and  inveterate  articular  gout  the  surrounding 
fibrous  tissue  may  become  impregnated  with  biurate,  and 
the  tendons  hkewise. 

The  pecuHar  attitude  and  deformity  of  the  gouty  hand 
are  often  due  to  the  imphcation  of  the  sheaths  of  the 
superficial  and  deep  flexors.  Dupuytren's  contraction,  in 
which  the  palmar  fascia,  and  the  sheaths,  but  not  the 
tendons,  are  affected,  and  the  analogous  contraction  of  the 
plantar  fascia,  are  very  commonly  met  with  in  those  who 
are  free  from  the  major  manifestations  of  gout ;  and  much 
discussion  has  arisen  in  connection  with  the  aetiology  of 
these  lesions,  and,  in  individual  cases,  as  to  the  presence 
or  absence  of  the  disease.  In  the  lower  limb  the  tendo 
Achillis  and  the  peronsei  are  specially  liable. 

At  a  distance  from  joints,  in  situations  where  it  is 
exposed  to  much  pressure  or  cold,  and  particularly  in  the 
palmar  and  plantar  fascise,  fibrous  tissue  is  independently 
liable  to  gouty  deposits  or  to  gouty  inflammation.  Dupuy- 
tren's contraction  is,  with  Heberden's  nodules,  among  the 
S3^mptoms  of  an  ill-developed  and  very  chronic  variety  of 
gout. 

Bursce  are  well  known  to  be  liable  to  gouty  inflamma- 
tion, quite  independently  of  any  concomitant  arthritis,  but 
the  two  affections  may  coincide.  '  Crab's  eyes '  is  the 
name  given  to  small  cysts,  probably  bursal,  apt  to  form 
over  Heberden's  nodules  or  behind  the  nail.*  Bursse, 
such  as  those  of  the  metatarsal  bones,  and  particularly  of 
the  great  toe,  of  the  heel,  knee,  and  olecranon,  are  specially 
liable  to  incrustations  and  thickening  from  gouty  inflamma- 
tion. Those  over  the  ischium  and  trochanter  are,  like  the 
hip-joint  itself,  rarely  affected. 

Gouty   bursitis   claims    importance   in    connection   with 
peri-articular  and  intra-articular  stippuration.     Suppuration 
*  Cf.  Duckworth,  loc.  cit.^  p.  83. 


I20    HEMORRHAGE,  SUPPURATION,  AND  GANGRENE 


of  the  gouty  joints  being  unusual,  whilst  bursal  abscess  is 
fairly  common,  and  is  sometimes  seen  in  gout  where  the 
neighbouring  joints  contain  no  pus,  the  formation  of  an 
abscess  as  a  late  event  in  gouty  arthritis  is  regarded  by 
some  as  always  occurring  from  an  extension  of  a  bursal 
abscess.* 


HEMORRHAGE,  SUPPURATION,  AND  GANGRENE. 

Free  hcsmorrhage  into  gouty  joints  has  been  seldom 
recorded ;  but  a  slight  oozing  of  blood  from  a  congested 
synovial  membrane  not  infrequently  stains  their  contents. 

Stcppuration  is  not  the  normal  tendency  of  gouty  inflam- 
mation. Nevertheless,  in  a  few  cases,  pus  may  form  in 
connection  with  some  unusual  irritation  in  the  inflamed 
part.  As  previously  stated,  this  is  more  often  seen  in  a 
gouty  bursa  than  in  gouty  joints.  In  the  latter  the  fluid 
may  present  a  puriform  appearance,  owing  to  the  presence 
of  loose  urates  in  the  altered  synovial  fluid,  and  the  irrita- 
tion produced  by  them  may  lead  to  the  admixture  of  a 
little  pus. 

The  non-suppurative  course  observed  in  the  frequently 
spontaneous  process  of  outward  discharge  of  tophaceous 
matter  is  significant  of  the  relatively  slight  proneness  of 
gouty  tissues  to  suppuration. 

Gangrene  does  not  occur  in  sthenic  gout.  It  is  mainly 
observed  in  advanced  gouty  degeneracy,  and  especially 
under  the  influence  of  senile  atheroma  or  diabetes,  its 
determining  cause  being  generally  some  accidental  lesion 
or  pressure.  It  may,  however,  be  the  accompaniment  of 
a  direct  arthritis  :  an  instance  of  this  kind  is  given  by 
Duckworth,^  without,  however,  any  particulars. 

*  C/.  Ollivier,  quoted  by  Rendu,  /oc.  a'/.,  p.  26. 
i  Loc.  cit.,  p.  83. 


TOPHI  121 

TOPHI. 

Subcutaneous  uratic  infiltration  of  the  connective  tissue, 
involving  the  deeper  layer  of  the  derma,  is  apt  to  lead,  in 
the  worst  cases,  to  a  stiff  hide-bound  condition  ;  the  ulcera- 
tion of  these  diffused  infiltrating  deposits  is  troublesome 
in  proportion  to  their  extent. 

Localised  subcutaneous  tophi  are  to  be  looked  for  in  two 
situations.  Lecorche  has  described  their  occurrence  as 
minute  deposits  in  the  thickness  of  the  skin  of  the  palmar 
aspect  of  the  fingers,  where  they  are  apt  to  ulcerate  and 
leave  characteristic  scars.  Still  more  common  and  diag- 
nostic are  the  tophi  (present  in  one-half  of  the  cases  ac- 
cording to  Garrod)  in  the  helix  or  antihelix  of  the  ear,  or  in 
the  groove  between  them.  Various  other  situations  may 
present  deposits — the  eyelids,  nostrils,  or  even  the  cheek, 
the  skin  of  the  fore-arm  along  its  ulnar  border,  that  of  the 
shin,  sometimes  the  skin  of  the  thigh,  or  that  covering 
the  corpora  cavernosa.* 

The  chemical  composition  of  tophi  is  somewhat  variable, 
especially  in  respect  of  the  amount  of  sodium  and  calcium 
urate ;  it  is  estimated  by  Sir  Dyce  Duckworth  at  about 
10  per  cent,  of  sodium  chloride,  and  50  per  cent,  of  the 
biurates,  with  some  calcium  phosphate  and  animal  matter.f 
According  to  Sir  A.  Garrod,  they  consist  essentially  of 
crystallized  sodium  urate,  and  the  lime  is  only  an  accidental 
constituent.  Sir  Andrew  Clark  reported  in  one  case  a 
large  amount  of  calcium  oxalate,  and  believed  in  the 
frequent  presence  of  calcium  urate  crystals.  From  all 
accounts,  the  deposits  are  therefore  liable  to  variations, 
and  calcium  is  seldom  absent,  although  its  quantity  may 
be  small.  The  consistency  of  a  tophus  is  also  variable ; 
unlike  the  pure  calcareous  deposit,  it  tends  to  soften  with 

*  Cf.  Rendu,  loc.  cit.^  p.  28.  t  Loc.  cit.,  p.  92. 


122  TOPHI 

age.  In  those  cases  where  it  ultimately  disappears,  we 
observe  a  gradual  return  towards  the  soluble  state  in 
which  it  was  originally  deposited. 

According  to  Rendu,*  Tennant  and  Pearson  were  the 
first  to  demonstrate  uric  acid  in  gouty  deposits.  Fourcroy  t 
and  Wollastont  confirmed  this  discovery,  and  showed  that 
they  almost  exclusively  consisted  of  urate  of  soda.  Later 
observations  have  shown  that  the  composition  may  vary 
slightly,  but  is  for  the  greater  part  sodium  biurate,  with 
which  is  generally  mixed  a  small  amount  of  calcium  urate, 
some  sodium  and  potassium  chloride,  and  organic  matter. 
Applied  to  gouty  deposits  the  term  '  chalky'  is  a  misnomer; 
for,  as  shown  by  the  absence  of  effervescence  on  adding 
acid  to  them,  there  is  no  carbonate  of  lime.  Phosphate  of 
lime,  when  found,  is  probably  derived  from  the  softened 
bone  substance. 

The  reagents  to  be  employed  in  examining  the  deposits 
are  :  hydrochloric  acid,  which  shows  the  absence  of  effer- 
vescence, and  therefore  of  calcium  carbonate ;  nitric  acid, 
with  which  the  murexide  test  is  performed ;  ignition,  to 
identify  the  organic  nature  of  the  deposit  and  to  separate 
the  ash ;  nitrate  of  silver,  which  shows  in  the  latter  the 
presence  of  chlorides ;  and  lastly  acetic  acid,  which  dis- 
solves the  biurate  and  precipitates  from  it  the  uric  acid. 

*  Loc.  cit,  p.  28. 

t  '  Systeme  des  Connaiss.  Physiques,'  t.  x.,  p.  267. 

"I  '  Philos.  Trans.,'  1797,  p.  386. 


CHAPTER  XVI. 

THE  CARDIAC  AND  VASCULAR  LESIONS  IN 

GOUT. 

THE  HEART. 

We  should  expect  in  association  with  gout  pre-eminently 
those  cardiac  lesions  which  are  related  to  organic  or  to 
functional  vascular  disease,  and  particularly  to  granular 
kidney  and  arterio-capillary  fibrosis. 

Pericarditis  may  occur  in  gout,  but  chiefly  as  a  chronic 
change.  In  gouty-renal  cachexia  it  is  sometimes  a  fatal 
complication.  It  is  noteworthy  that  Dickinson  found 
recent  pericardial  changes  in  i6  out  of  68  cases  of  granular 
kidney  from  all  causes;  and  Dr.  N.  Moore  in  80  cases  of 
gout  noted  them  in  12  instances,  all  being  cases  of  granular 
kidney. 

The  myocardial  changes  are  either  those  of  fatty  degene- 
ration, or  more  commonly  those  of  hypertrophy.  Rendu* 
asserts  that  granular  kidney,  when  due  to  uratic  gout, 
instead  of  leading  to  the  customary  hypertrophy  of  the 
left  ventricle,  is  associated  with  a  thinning  of  the  wall  and 
a  tendency  to  fatty  infiltration  and  to  fatty  degeneration. 
The  cases  to  which  he  refers  must  have  belonged  to  the 
class  of  coronary  disease.  In  any  given  case  the  variety 
of  the  myocardial  lesion  may  be  said  to  depend  upon  the 
state  of  the  kidneys  and  of  the  coronary  vessels. 

*  Loc.  cit.^  p.  34. 


124  THE  HEART 


Gouty  endocarditis  can  only  be  described  as  a  slow  fibroid 
degeneration  affecting  mainly  the  free  edges  of  the  valves, 
and  gradually  causing  them  to  thicken  and  to  shrink.* 
The  undoubted  association  between  this  change  and  gout 
is  an  important  pathological  fact,  to  be  correlated  with  the 
yet  more  frequent  association  between  rheumatism  and 
sclerosis  of  the  valves.  It  is,  however,  in  gout  a  far  more 
gradual  and  chronic  process  than  in  rheumatism,  and 
commonly  it  is  associated  not  only  with  the  usual  uratic 
joints,  but  with  gouty  degeneration  of  the  vessels. 

Uric  acid  has  only  rarely  been  found  in  connection 
with  the  heart.  Garrod  detected  it  in  gouty  pericardial 
effusion.  Ebstein's  case  is  the  only  recorded  instance  of 
a  uratic  deposit  in  the  myocardium ;  degenerative  cellular 
changes  were  also  found  in  the  vicinity  of  the  nodules. 
An  infiltration  of  the  cardiac  valves  with  biurate  has  been 
described  from  time  to  time.  In  the  case  reported  by 
Sydney  Couplandf  the  aortic  valve  was  affected  —  the 
mitral  in  Lancereaux's  two  cases.+ 

THE  ARTERIES  AND  ATHEROMA. 

Whilst  true  uratic  deposit  has  rarely  been  reported,§ 
arterial  disease,  or,  to  call  it  by  its  pathological  name, 
atheroma  of  the  deep  layer  of  the  intima,  is  exceedingly 
common  in  gout.     The  preference  shown  by  atheroma  in 

*  Murchison,  quoted  by  Duckworth,  loc.  cii.,  p.  109,  regarded  arterial 
atheroma  of  early  life  and  non-rheumatic  aortic  valve  disease  as 
occurring  chiefly  in  the  subjects  of  uric  acid  dyscrasia  or  of  gout. 

t  La?icet,  March,  1873. 

X  Gas.  Med.  de  Paris,  1868,  p.  187,  '  Traite  d'Anat.   Path.,'  t.   ii., 

p.  729- 

§  Landerer,  Buchner's  Report,  bd.  xiv.,  p.  60,  1847  ;  Bramson, 
Zeitsch.  fiir  Rat.  Med.,  1845,  t.  iii.  ;  Bence  Jones,  Laftcet,  1856- 
Cf.  Rendu,  loc.  cit,  p.  36.  Dr.  Norman  Moore  has  described  uric 
acid  deposits  in  the  renal  artery  itself.     Cf.  Duckworth,  p.  109. 


THE  ARTERIES  AND  ATHEROMA  125 

this  disease  for  the  coronary  and  for  the  cerebral  vessels 
is  fraught  with  much  clinical  and  pathological  importance. 

The  great  liability  to  cerebral  haemorrhage  and  to  degene- 
rative cardiac  disease,  both  of  which  belong  to  an  advanced 
stage  of  the  vascular  degeneracy,  adds  special  interest  to 
the  rarity  of  aneurysm.  Again,  in  spite  of  the  tendency  to 
arterial  obstruction  which  would  result  from  atheromatous 
thickening,  arterial  thrombosis  and  gangrene  from  throm- 
bosis are  rare  (Duckworth),  in  striking  contrast  to  the 
frequency  of  thrombosis  in  the  veins. 

The  JEttology  of  Atheroma. — The  close  association  of 
chronic  gout  with  chronic  disease  of  the  kidney  explains 
the  special  liability  of  gouty  subjects  to  arterial  disease. 
Inasmuch  as  vascular  atheroma  is  common  among  those 
whose  interstitial  nephritis  has  no  connection  with  gout,* 
nor  with  a  gouty  family  history,  we  cannot  regard  chronic 
endarteritis  as  specifically  gouty,  but  we  recognise  its 
direct  setiological  relation  with  renal  disease.  At  the 
same  time,  the  constitutional  influences  which  so  largely 
determine  kidney  trouble  among  sufferers  from  gout  may 
favour  in  them  arterial  degeneracy  over  and  above  the 
proportion  normally  traceable  to  kidney  disease.  This 
impression  finds  strong  support  in  the  tendency  to  arterial 
degeneration  so  often  traced,  like  gout  itself,  through 
several  generations.  If  both  tendencies  should  happen  to 
be  simultaneously  inherited,  they  could  not  but  aggravate 
each  other ;  and,  independently  of  any  such  double  in- 
heritance, it  is  conceivable  that  a  gouty  cachexia  might 
intensify  the  arterial  changes  special  to  kidney  disease. 

Peter  has  applied  to  atheroma  the  expression  rouille  de 
la  vie ;  but  the  idea  of  the  '  rust  of  life '  is  perhaps  more 
applicable  to  gout  itself,  with  its  premature  degenerative 

*  It  is  significant  that  Professor  Osier,  who  has  noticed  the  great 
prevalence  of  atheroma  in  Baltimore,  has  very  rarely  met  with  gout. 


126  THE  ARTERIES  AND  ATHEROMA 


changes  and  its  freely  circulating  debris.  Atheroma  is 
found  in  all  conditions  of  renal  inadequacy,  leading  to 
autotoxis,  as  well  as  in  habitual  toxsemia  ab  ingestis  (alcohol, 
lead,  etc.),  and  therefore  pre-eminently  in  gout  also,  where 
both  are  present.  The  aetiology  of  atheroma  is  too  extensive 
to  be  fully  discussed  in  these  pages.  The  prevaihng  view 
is  that  it  arises  from  excessive  intra-arterial  pressure,  and 
as  an  inevitable  senile  change  ;  but  the  writer  has  long 
felt  that  evidence  does  not  absolutely  warrant  such  a  con- 
clusion. It  should  be  borne  in  mind  that  the  causes  which 
bring  about  the  increased  pressure  have  the  earliest  oppor- 
tunity of  exerting  a  direct  influence  on  the  intima  itself 
which  is  in  contact  with  the  blood. 

It  has  been  suggested  :  (i)  that  the  intima  is,  as  it  were, 
caught  between  the  anvil  and  the  hammer ;  (2)  that  the 
vasa  vasorum  are  flattened  by  lateral  pressure,  and  that 
the  intima  thus  suffers  malnutrition.  These  explanations 
are  almost  too  mechanical.  Do  they  apply  in  the  case  of 
syphilis  ?  Dr.  Oliver's  studies  with  the  arterial  pressure- 
gauge  suggest  that  they  may ;  for  he  finds  in  syphilis  that 
absence  of  the  reaction  to  posture,  which  he  identifies 
with  increased  arterial  tension.  On  the  other  hand,  we 
have  here  an  obvious  toxic  factor ;  and  the  same  may  be 
said  of  gout,  of  kidney  disease,  and  of  all  conditions  due 
to  a  contamination  of  the  blood  from  excessive  alimenta- 
tion, or  to  an  imperfect  oxidation  and  emunction,  as  in 
visceral  torpor.  Dr.  W.  A.  Hollis*  has  recently  put  for- 
ward the  view  that  atheroma  may  be  original^  due  to 
bacterial  and  other  impurities  in  the  blood,  the  lining  mem- 
brane becoming  subsequently  infiltrated  with  the  retiring 
swarms  of  phagocytes.  He  also  explains  its  special  locali- 
zation at  the  mouths  of  the  smaller  arterial  branches  in 
the  aorta. 

*  'Atheroma,'  Journal  of  Pathology,  vol.  iii.,  No.  i,  November, 
1894,  and  No.  4,  January,  1856. 


THE  ARTERIES  AND  ATHEROMA  127 

The  special  liability  in  gout  of  the  coronary  and  cerebral 
vessels  is  suggestive  in  an  setiological  sense.  Both  these 
vascular  systems  are  largely  dependent  for  their  oscilla- 
tions in  pressure  upon  the  influence  of  general  muscular 
activity.  The  latter  may  be  regarded  as  periodically  in- 
creasing the  tension  within  the  cerebral  and  coronary 
vessels  in  connection  with  the  variations  in  the  blood 
capacity  of  the  contracting  muscles  ;  the  relief  afforded  to 
the  overworked  nervous  system  by  muscular  work  has, 
indeed,  been  attributed  to  this  agency.  The  neglect  of 
muscular  exertion,  absolute  or  relative,  which  is  a  recog- 
nised factor  in  the  production  of  gout,  might,  if  these  views 
be  correct,  be  held  in  part  responsible  for  the  degenerative 
changes  occurring  with  undoubted  frequency  in  the  cerebral 
and  coronary  arteries  of  the  gouty. 

In  its  setiolog}^,  gouty  atheroma  is  probably  not  essen- 
tially different  from  other  forms,  and  not  the  product  of  a 
specific  gouty  endarteritis.  Here,  as  elsewhere  in  gout, 
we  have  to  deal  with  faulty  nutrition  and  its  results  ;  the 
impurity  of  the  blood  may  act  as  an  irritant  to  the  arterial 
lining,  and  the  latter  is  more  prone  to  resent  the  irritation 
because  participating  in  the  malnutrition  from  which  all 
the  tissues  are  more  or  less  suffering.  The  constriction 
of  the  vasa  vasorum  and  the  permanently  raised  arterial 
tension,  though  they  may  not  be  the  most  essential  factors, 
must  nevertheless  be  considered  as  contributing  largely  to 
the  arterial  degeneration,  since  the  stress  is  thrown  upon 
already  weakened  structures. 

THE  CAPILLARIES. 

In  all  diseases  of  malnutrition  the  mischief  concerns 

the  infinitely  small.     With  the  naked  eye  we  can  only 

trace  the  coarse  lesions.     A  study  of  the  capillaries  would 

bring  us  nearer  to  the  seat  of  trouble.     This  study  has  yet 


128  THE  CAPILLARIES 

to  be  undertaken,  and  for  the  present  \ve  can  only  infer 
that  capillary  malnutrition,  impairment  of  function,  and 
degeneracy  precede  the  degeneration  of  tissues  in  general 
(with  the  notable  exception  of  the  extravascular  tissues 
SQch  as  cartilage,  the  relatively  early  decay  of  which  con- 
firms the  view  that  degeneration  begins  in  the  intimate 
structure  of  cells).  The  nutrition  of  the  capillary  wall 
undoubtedly  suffers  in  sympathy  with  that  of  the  tissues 
on  the  one  hand,  and  with  the  arterial  degeneration  on 
the  other.  Evidence  of  deficient  resistance  is  sometimes 
given  in  the  occurrence  of  capillary  haemorrhages  from 
the  synovial,  but  especially  from  the  mucous  membranes. 
Hitherto,  however,  no  specially  '  gouty  '  change  has  been 
traced  in  the  capillaries. 

THE  VEINS  AND  PHLEBITIS. 

The  affections  of  the  veins  constitute  an  important 
chapter  in  the  clinical  history  of  gout ;  but  there  is  com- 
paratively little  to  note  in  their  morbid  anatomy.  Atheroma 
is  not  a  disease  of  veins.  Uratic  incrustations,  which  are 
regarded  as  rare  in  the  arterial  system,  may,  however, 
occur,  though  with  yet  greater  rarity,  in  the  veins. 

Schroeder  van  der  Kolk  relates  an  instance  of  this  kind 
in  which  the  valves  of  the  veins  were  also  incrusted ;  the 
arteries  were  not  the  seat  of  this  change. 

The  veins  are  conspicuously  affected,  not  only  during 
the  gouty  paroxysm,  which  by  some  has  even  been  described 
as  a  '  phlebitis,'  and  which  always  occasions  a  dilatation  of 
one  or  more  of  the  superficial  veins,  but  also  in  the  shape 
of  chronic  dilatation  and  thickening,  and  of  the  acute 
thrombosis  usually,  and  probably  with  good  reason,  re- 
garded as  due  to  a  gouty  phlebitis. 

It  might  be  possible,  as  suggested  by  Rendu,*  to  draw 
*  Loc.  at,  p.  sy. 


THE   VEINS  AND  PHLEBITIS  129 

a  clinical  parallel  between  the  gouty  atheroma  of  arteries 
and  the  atojty  and  varicosity  so  often  seen  in  the  veins  of 
the  gouty,  and  to  trace  these  likewise  to  a  disease  of  the 
vasa  vasorum  ;  but  the  writer  is  unable  to  view  the  tendency 
to  dilatation  and  to  resulting  oedema  as  '  direct  conse- 
quences '  of  a  gouty  '  diathesis,'  whatever  may  be  meant 
by  that  term.  As  in  the  case  of  the  arteries,  the  yielding 
of  the  vessel  wall  is  in  great  part  due  to  malnutrition, 
coupled  with  the  increased  venous  fulness  and  pressure 
due  to  hepatic  congestion,  itself  the  outcome  of  faulty  diet 
and  deficient  exercise. 

The  venous  circulation  is  almost  entirely  carried  on  by 
lateral  pressure.  Any  circumstance,  and,  above  all,  well- 
regulated  exercise,  raising  the  general  tone  and  firmness 
of  the  surroundings  of  veins,  helps  the  circulation  within 
them,  and  saves  them  from  distension.  On  the  other 
hand,  direct  innervation  enters  largely  into  the  question 
of  venous  tone  ;  and  this  is  equally  manifest  in  the  yielding 
of  the  subcutaneous  veins  from  excessive  fatigue,  and  in 
the  opposite  effect  produced  by  rest,  or,  in  an  eminent 
degree,  by  change  to  a  bracing  atmosphere. 

VISCERAL  HEMORRHAGES  IN  GOUT— CEREBRAL, 
PULMONARY,  AND  OTHERS. 

The  haemorrhages  from  varicose  veins,  from  haemor- 
rhoids, from  the  bladder,  and  in  the  so-called  hasmorrhagic 
retinitis,  of  which  Mr.  J.  Hutchinson  has  investigated  the 
relations  with  gout,*  need  only  a  passing  mention. 

Cerebral  Hcemorrhage. — As  in  non-gouty  granular  kidney 
disease,  the  brain  is  the  most  common  seat  of  arterial 
rupture.  Cerebral  haemorrhage  is  due  to  a  conjunction  in 
the  brain  of  opposite  vascular  changes,  the  contrast  between 
the  thickened  and  toughened  condition  of  some  parts  of 
*  '  Clin.  Soc.  Trans.,'  1878,  vol.  xi. 

9 


I30  VISCERAL  HEMORRHAGES  IN  GOUT 

the  vessels,  and  their  thinned,  bulging,  and  brittle  wall  in 
other  parts,  being  most  conspicuous  in  this  organ.  Haemor- 
rhage usually  occurs  late  in  cases  of  gout,  and,  as  pointed 
out  by  Dr.  Southey,  after  the  degenerative  changes  leading 
to  dilatation  have  begun  in  the  hypertrophied  myocardium.* 

In  a  series  of  thirty-two  cases  of  cerebral  haemorrhage, 
Norman  Moore  found  uratic  deposits  in  thirteen,  the  ages 
of  the  subjects  varying  from  twenty-eight  to  sixty-six. t 

The  Senile  Pulmonary  Hcemorrhage  of  Arthritic  Constitu- 
tions.— Of  great  pathological  interest  and  clinical  import- 
ance is  the  sometimes  profuse  haemoptysis  apt  to  occur, 
although  rarely,  in  somewhat  advanced  life,  not  traceable 
to  any  causes  but  emphysema,  and  a  gouty  tendency 
either  declared  or  latent.  This  remarkable  affection  was 
first  described  by  Sir  Andrew  Clark,|  and  little  need  be 
added  to  his  masterly  sketch.  The  writer  has  observed 
precisely  the  conditions  described  in  an  elderly  female 
patient,  in  whom  gout  had  never  come  to  the  stage  of 
arthritis,  but  the  gouty  tendency  was  manifested  in  a 
variety  of  smaller  symptoms.  It  must  be  inferred  that  the 
vascular  condition  is  one  of  weakness,  probably  connected 
with  changes  in  the  pulmonary  artery  identical  with  the 
atheroma  almost  constantly  found  in  the  systemic  arteries 
of  gouty  subjects. 

THE  LYMPHATICS,  AND  GOUTY  LYMPHANGITIS. 

That  the  lymphatic  system  must  be  inseparably  con- 
nected with  the  pathology  of  gout  is  almost  a  truism. 
There  is,  however,  little  outward  evidence  of  its  participa- 
tion in  the  morbid  events.  The  absence  of  any  coarse 
changes  in  the  glands  and  in  the  larger  vessels  does  not, 
however,  exclude  the  probability  of  intimate  changes  in  the 

*  Cf.  Duckworth,  loc.  cit.,  p.  109.  t  Ibid. 

%  'Med.  Soc.  Trans.,'  vol.  xiii.,  1890,  p.  9. 


THE  LYMPHATICS,  AND  GOUTY  LYMPHANGITIS     131 

chemical  composition  and  in  the  cellular  structure  of  their 
contents.  There  is  in  this  direction  a  wide  field  open  for 
future  investigation.  On  the  other  hand,  an  occasional 
implication  of  the  peripheral  lymphatics  belongs  to  the 
best-known  clinical  phenomena  of  gouty  inflammation,  and 
in  connection  with  them  reference  will  be  made  to  the 
combination  of  lymphangitis  with  phlebitis  in  phlegmasia 
alba  dolens. 

Gouty  Lymphangitis. — Whether  the  acute  attack  of  gout 
may  be  regarded  or  not  as  intimately  bound  up  with 
inflammation  of  the  lymphatics  of  the  part,  or  whether 
phlebitis  has  a  larger  share  in  the  production  of  the 
oedema,  is  a  question  which  needs  for  its  solution  further 
clinical  observation.  To  say  nothing  of  the  strong  analogy, 
with  differences,  presented  by  the  acute  rheumatic  joint 
affection,  in  which  the  lymphatic  implication  is  unquestion- 
able, various  features  belong  to  the  acute  gouty  swelling 
which  remind  us  of  the  results  of  acute  irritation  of 
lymphatic  capillaries.  On  the  other  hand,  there  is  no 
evidence  that  lymphangitis  of  the  larger  trunks  forms  part 
of  the  process. 

Gouty  lymphangitis  itself  is  apt  to  occur  entirely  in- 
dependently of  the  arthritic,  seizure  ;  but  its  gouty  nature 
is  attested  by  unmistakable  evidence  in  some  cases.  At 
other  times  it  is  doubtful  whether  it  had  been  set  up 
spontaneously,  as  seems  to  be  the  case  with  gouty  phlebitis, 
or  as  a  result  of  some  unnoticed  cutaneous  lesion. 

Gouty  lymphangitis  may  occur  in  connection  with  ulcera- 
tion of  tophi.  Erysipelas  or  gangrene  has  repeatedly  been 
observed  after  surgical  interference  with  the  deposits,  and 
this  liability  strongly  discourages  their  removal  by  the  knife. 

The  course  of  the  affection  is  not  different  from  that  of 
ordinary  lymphangitis.  Suppuration  may  occur,  or,  in 
severe  cases,  diffuse  inflammation  and  sloughing. 


CHAPTER  XVII. 

THE  VISCERAL  LESIONS  IN  GOUT.* 

THE  MUCOUS  MEMBRANES. 

With  the  exception  of  the  lining  membrane  of  the  upper 
respiratory  tract,  the  mucous  membranes  are  not  favour- 
ably situated  for  a  study  of  the  gouty  changes.  From 
analogy,  and  from  a  study  of  the  symptoms,  we  may  infer 
that  vascular  and  vaso-motor  changes  analogous  to  those 
to  be  described  later  in  the  pharynx,  may  be  set  up  in  the 
stomach  and  intestine.  But  concerning  these  questions 
our  attitude  is  one  of  reserve  until  some  further  light  is 
obtained.  With  the  exception  of  an  instance  recorded  by 
De  Mussy,t  in  which  the  pharyngeal  follicles  discharged 
carbonate  and  urate  of  lime,  and  of  Hayem's  unique  obser- 
vation of  a  fine  uratic  incrustation  of  the  intestinal  villi, :t 
mucous  membranes  have  not  been  suspected  of  any 
liability  to  uratic  deposits ;  but  here  again  further  search 
is  indicated. 

GOUTY  LARYNGITIS,  TRACHEITIS,  AND  BRONCHITIS. 

The  mucous  membrane   of  the  respiratory  tract  is,  in 
this  country,  exceedingly  prone  to  suffer  in  those  who  are 

*  Additional  data  concerning  organs  not  mentioned  here  will  be 
found  in  the  clinical  and  pathological  sections. 

■f   Union  Med.,  xviii.,  1856.  t  Rendu,  loc.  cit.,  p.  40. 


THE  MUCOUS  MEMBRANES  133 

gouty,  and  we  have  been  led  to  speak  of  the  conditions  as 
'  gouty  laryngitis,  tracheitis,  and  bronchitis.'  Uratic 
deposits,  on  the  other  hand,  are  rare  in  any  part  of  the 
respiratory  system,  but  especially  rare  in  the  lung  itself — 
the  least  unusual  site  being  the  larynx,  and  the  air-passages 
being  also  liable  in  a  feeble  proportion.  Thus,  Bence 
Jones  has  described  gouty  deposits  in  the  bronchial  wall. 
The  uratic  expectoration  described  by  various  authors 
might  conceivably  have  had  the  same  derivation ;  but, 
with  greater  probability,  it  was  due  to  the  ulceration  of 
laryngeal  tophi.  Gouty  deposits  in  the  larynx  have  been 
reported  from  time  to  time  by  reliable  observers,  including 
Virchow  and  Sir  A.  Garrod.  Their  situation  has  generally 
been  the  vocal  cords  or  the  cartilages.  These  facts  are  in 
complete  harmony  with  the  extensive  clinical  evidence 
pointing  to  gouty  irritation  of  the  laryngeal  mucous 
membrane. 

Gouty  bronchitis  occupies  a  larger  place  in  the  clinical 
history  of  gout — in  connection  with  which  it  will  be 
described — than  in  its  morbid  anatomy.  It  probably  is  in 
a  great  measure,  though  not  wholly,  answerable  for  the 
frequency  of  emphysema.  Pleural  adhesions,  chronic 
interstitial  and  pneumonic  changes,  associated  with  dilated 
bronchi,  are  not  infrequently  seen. 

Pulmonary  tuberculosis  is  unusual  in  the  gouty,  except 
in  profound  cachexia,  but  not  unusual  in  their  offspring. 

GOUTY  EMPHYSEMA. 

The  prevailing  anatomical  pulmonary  lesion  in  gout  is 
emphysema,  as  bronchitis  is  the  prevailing  clinical  ailment. 
It  would  seem,  however,  that  chronic  bronchial  catarrh 
and  the  mechanical  stress  of  cough  are  not  necessarily 
forerunners  of  the  change.     Dr.  Norman  Moore  has  found 


134  GOUTY  EMPHYSEMA 

emphysema  in  so  large  a  proportion  of  cases  of  inveterate 
gout  that  the  numbers  must  include  many  cases  in  which 
bronchitis  could  not  have  been  alleged  as  a  sufficient  cause. 
He  is  inclined  to  regard  emphysema  as  hardly  less  frequent 
in  gout  than  interstitial  nephritis.  This  view  entirely 
agrees  with  the  estimate  which  is  taken  of  gout  in  these 
pages.  The  pulmonary  atrophy  is  part  of  the  general 
malnutrition  of  the  tissues,  and  the  change  is  specially 
marked  because  the  lung  is  essentially  a  part  of  the  vascular 
system,  and  therefore  subject  in  a  high  degree  to  the 
influences  arising  from  the  blood ;  and  it  is  probably  also 
connected  with  the  enormous  extent  of  the  delicate  and 
perishable  capillary  system,  and  with  the  high  proportion 
of  the  elastic  and  fibrous  elements  in  the  pulmonary  struc- 
ture— both  elements  being  known  for  the  slowness  of  their 
nutritive  changes,  and  one  of  them  at  least  (the  fibrous) 
being  undoubtedly  obnoxious  to  gout. 

The  frequency  of  emphysema  has  much  clinical  sig- 
nificance of  a  general  kind,  and  especially  in  connection 
with  pulmonary  haemorrhage,  the  occasional  occurrence  of 
which  has  been  pointed  out. 

THE  KIDNEY. 

The  'gouty  kidney'  is  the  small  granular  kidney  de- 
scribed by  Todd,  George  Johnson,  Dickinson,  Garrod, 
Charcot,  Cornil,  and  others.  Thickening  of  the  capsule, 
shrinking  of  the  organ,  and  granulation  of  its  surface  with 
cortical  atrophy,  are  the  well-known  characteristics  of  the 
disease.  On  section,  an  almost  fibrous  toughness  and 
a  flesh}^  redness  are  described  b}^  Dickinson  as  belonging 
to  the  gouty  kidney,  though  not  exclusively  to  this.  An 
additional  feature,  which  may  identify  the  granular  kidney 
as  a  '  gouty  '  granular  kidney,  is  the  occasional  presence 
of  deposits  of  sodium  biurate,   whether  within  the  col- 


THE  KIDNEY  135 


lecting  tubes  (Charcot,  Cornil)  or  in  the  chronic  inflam- 
mator}^  interstitial  substance  (Garrod,  Rendu).  Ebstein 
points  out  that  gouty  subjects  sometimes  present  a 
granular  kidney  quite  free  from  any  uratic  deposit,  and 
that,  especially  in  those  who  have  previously  suffered  from 
gravel,  uric  acid  may  be  found  instead  of  biurate.  Accord- 
ing to  Duckworth,  deposits  are  rarely  found  in  the  kidneys 
of  the  gouty.  Might  this  not  be  the  result  of  the  solvent 
treatment,  or  even  of  the  diuresis  special  to  granular 
kidney  ? 

Whether  it  be  complicated  with  deposits  or  free  from 
them,  granular  kidney  is  usually  regarded  as  a  late  result 
of  gout.  It  is  most  often  found  in  those  whose  gouty 
record  is  of  long  duration,  and  Dickinson*  ascribes  to  the 
enduring  nature  of  the  cause  the  fact  that  the  gouty  kidney 
commonly  advances  to  the  most  extreme  degeneration  com- 
patible with  life.  Granular  disease  being  one  of  slow  pro- 
gression, it  is  difficult  to  estimate  the  date  of  its  earliest 
beginnings.  Levison  has  recently  sought  to  identify  it 
with  that  of  the  early  gouty  symptoms,  a  somewhat  extreme 
view,  which  has  been  combated  by  Lange,  but  which  is 
not  entirely  novel.  Virchow  long  ago  expressed  a  notion 
that  a  gouty  nephritis  might  exist  without  either  classical 
gout  or  uratic  deposits,  and  Duckworth  is  inclined  to 
admit  the  possibility  of  a  '  primary  gout  in  the  kidneys.' 
Complete  evidence  as  to  the  gout  having  been  primary 
in  the  kidney  is,  however,  difficult  to  secure,  since  a  quiet 
gout  in  the  joints  is  of  common  occurrence,  whilst,  on 
the  other  hand,  uratic  deposits  may  be  reabsorbed  in  the 
course  of  time  from  joints  previously  affected. 

Again,  Lancereaux-f-  has  described  in  chronic  rheumatic 
arthritis  a  variety  of  granular  kidney  consecutive  to 
chronic  alterations  in  the  arterial  system ;  in  other 
*  Loc.  cit.,  p.  157.  t  Q^  Duckworth,  loc.  cit.,  p.  100. 


136  THE  KIDNEY 


words,  an  arterio-sclerotic  form,  which  might  simulate 
the  strictly  gouty  variety. 

The  Relative  Frequency  of  Granular  Kidney  in  Gout. — 
On  this  important  question  Sir  Dyce  Duckworth*  has 
collected  evidence.  Ord  and  Greenfield f  found,  among 
the  hospital  cases  in  which  the  great  toe  was  affected, 
a  definite  co-existence  of  contracted  granular  kidney  in 
two-thirds,  and  in  the  remaining  one-third  renal  conditions 
closely  allied  to  the  latter.  In  96  cases  of  renal  disease 
there  were  at  least  8,  and  probably  9,  in  which  no  uratic 
deposits  were  found  in  the  joints. 

Dr.  Norman  Moore,  in  49  cases  of  chronic  interstitial 
nephritis  in  males,  found  uratic  deposits  in  22 ;  in  16 
females  they  were  present  in  5  cases. 

Dickinson's  69  fatal  cases  of  granular  kidney  included 
16  cases  of  gout.  It  is  to  be  observed,  however,  that  the 
joints  in  this  series  were  not  examined. 

The  Situation  of  the  Renal  Deposit. — Opinions  are  divided 
as  to  whether  the  depositions  originally  take  place  in  the 
tubules  or  in  the  intertubal  tissue.  According  to  Garrod, 
who  holds  that  acute  gout  sometimes  attacks  the  renal 
fibrous  tissue  before  the  joints,  setting  up  acute  pain  in 
the  loins,  and  temporary  albuminuria,  '  the  greater  part 
is  interstitial,  whereas  in  non-gouty  cases  the  tubular 
structure  is  specially  affected,  and  the  crystals  of  uric  acid 
and  biurate  are  larger,  though  far  less  widely  distributed.' 
The  same  view  is  shared  by  Charcot  and  others. 

Cornil  and  Ranvier  state  that  the  urates  are  primarily 
in  the  cells  which  are  the  centres  of  their  crystallization ; 
Senator  says  that  the  amorphous  salt  is  first  deposited 
in   the   tubular   epithelium,    thence    extending    into    the 

*  Loc.  cit.^  p.  100. 

t  'Transactions  of  the  International  Medical  Congress,'  London, 
1881,  p.  107. 


THE  KIDNEY  137 


interstitial  tissue  and  becoming  crystalline ;  Greenfield 
has  commonly  found  the  deposit  in  the  connective  tissue 
of  the  cortex,  but  rarely  in  the  tubules ;  and  Norman 
Moore,  in  80  cases  of  well-marked  gouty  arthritis,  found 
deposits  in  the  pyramids  in  6  cases,  in  the  tubules  in  6 
cases  ;  thus,  hardly  one-seventh  of  the  number  had  either 
tubal  or  interstitial  deposits.  Sir  Dyce  Duckworth,*  who 
quotes  these  authorities,  does  not  favour  the  idea  that 
gouty  kidney  depends  on  the  deposit,  or,  at  any  rate,  is 
constantly  associated  with  it.  He  also  refers,  in  connec- 
tion with  the  deposition  of  uratic  salts,  to  Paget's  observa- 
tion that  in  children  of  the  middle  and  upper  classes,  in 
whom  inheritance  of  the  diathesis  may  be  expected, 
calculus  of  any  kind  is  one  of  the  very  rarest  diseases. 
We  should  bear  in  mind  that  the  '  classes '  form  a  much 
smaller  aggregate  than  the  'masses,'  and  that  in  children 
of  the  poor  lithates  are  the  most  common  constituents  of 
stone.  Klebs  observes  that  urates  are  deposited  in  the 
pyramidal  tubes  in  very  young  children,  but  '  never  in 
those  whose  lungs  are  unexpanded.'  Lastly,  Fagge 
notices  that  '  uratic  deposits  in  the  kidney  are  common 
in  Germany  ;  gout  rare.' 

The  early  and  transient  renal  changes,  the  existence  of 
which  is  assumed  by  the  supporters  of  the  renal  theory 
of  gout,  need  not  be  of  the  same  order  as  those  ultimately 
leading  to  the  '  gouty  granular  atrophy.'  The  fact  that 
many  sufferers  from  acute  gout  preserve  to  the  last  per- 
fectly healthy  kidneys  points  to  the  opposite  conclusion. 
The  opportunity  of  ascertaining  what  these  lesions  may 
be,  if  they  exist,  occurs  but  rarely,  as  a  result  of  sudden 
or  accidental  death,  and  is  yet  more  rarely  utilized ;  for 
the  present  they  must  remain  matter  of  speculation, 
although  their  reality  is  stoutly  asserted  by  Levison. 
*  Loc.  cit.,  p.  103. 


138  THE  LIVER 


THE  LIVER. 

In  spite  of  a  full  recognition  of  the  importance  of  the 
liver  in  relation  to  gout,  no  organic  disease  of  the  liver 
has  been  discovered  by  modern  research.  Hepatic  cirrhosis 
has  not  been  made  out,  as  in  the  case  of  renal  cirrhosis, 
to  be  directly  traceable  to  this  affection.  Murchison, 
Trousseau,  Gairdner,  Ebstein,  and  others,  whose  inquiries 
have  been  specially  directed  to  this  point,  have  found  little 
evidence  of  its  occurrence  ;  whilst  Dr.  Norman  Moore's 
tables  teach  us,  as  we  were  prepared  to  learn,  that 
hepatic  cirrhosis  most  commonly  occurs  quite  indepen- 
dently of  any  uratic  articular  deposits.  Sir  Dyce  Duck- 
worth,* who  refers  to  these  authorities,  whilst  recognising 
that  much  hepatic  disease  is  strictly  referable  to  disturb- 
ance of  the  circulatory  system,  still  inclines  to  the  view 
that  true  cirrhosis  may  be  induced  by  gout.  At  the  same 
time  he  admits  fully  the  difficulty  in  proving  this  position. 
Dr.  Robson  Roose  draws  attention  to  the  facts  that 
gouty  cirrhosis  had  been  described  by  Trousseau,  and 
that  Budd  also  held  that  various  substances  besides 
alcohol  might  excite  perihepatitis,  and  that  the  cow  and 
the  pig  are  subject  to  a  hepatic  cirrhosis  obviously  not 
alcoholic. 

The  broad  conclusion  is  manifest  that  cirrhosis  of  the 
liver  is  not  among  the  usual  results  of  gout.  Even  the 
minor  evil  of  cholelithiasis  cannot  be  regarded  as  specially 
belonging  to,  although  frequently  observed  in,  gout. 

With  the  exception  of  the  chronic  changes  secondary 
to  pulmonary  or  cardiac  disease,  we  are  not  familiar  with 
any  other  naked-eye  lesions,  and  their  absence,  in  itself, 
renders  improbable  the  existence  of  any  minute  textural 
changes  in  the  organ.  Nevertheless,  the  prominence  of 
*  Loc.  cit.,  p.  no. 


THE  LIVER  139 


the  hepatic  symptoms  in  the  clinical  history  of  the 
disease  warrants  the  assumption  of  functional  disturb- 
ances in  the  portal  and  in  the  biliary  circulation,  the 
evidence  of  which  is  more  readily  supplied  by  clinical 
than  by  anatomical  investigation.  We  are  also  justified 
in  suspecting  that  the  hepatic  metabolism  is  liable  in 
gout  to  profound  alterations,  which  need  not,  however, 
be  bound  up  with  obvious  changes  in  the  intimate 
structure. 

Biliary  Lithiasis. — The  frequency  of  this  complication 
is  variously  estimated  by  different  observers.  Dr.  N. 
Moore  found  only  three  cases  of  biliary  calculi  in  eighty 
cases  of  gout.  Sir  Dyce  Duckworth,  however,  regards 
biliary  lithiasis  as  not  infrequent  in  gouty  families.  Renal 
and  biliary  calculi  not  infrequently  coincide.  He  also 
observes  that  gallstones  are  somewhat  rare  after  fifty,  and 
also  rare  in  hot  climates. 


THE  NERVOUS  SYSTEM. 

Even  less  than  in  the  case  of  the  kidney  or  of  the  liver 
can  it  be  said  of  the  nervous  system  that  its  morbid 
anatomy  justifies  the  position  which  has  been  allotted  to 
it  in  the  aetiology,  or  that  to  which  it  is  entitled  in  the 
symptomatology  of  gout.  Apart  from  the  coarse  lesions 
resulting  from  atheroma  and  haemorrhage,  to  which  refer- 
ence is  made  under  the  heading  of  the  vascular  system, 
hardly  any  change  has  been  discovered  in  explanation  of 
the  varied,  and  often  severe,  clinical  events.  Even  diabetes, 
which,  after  apoplexy,  is  the  worst  nervous  disorder  in 
gout,  possesses  no  morbid  anatomy. 

Uratic  deposit  is  rare  in  any  situation,  yet  it  has  been 
observed  in  the  meninges  in  a  few  instances  :  by  Cornil 
in  the  cerebro-spinal  fluid  ;  by  Albert  and  Ollivier  on  the 


I40  THE  NERVOUS  SYSTEM 

spinal  meninges  (in  one  case  the  lightning  pains  of  tabes 
had  been  diagnosed  by  Ollivier) ;  by  Charcot  in  the  sub- 
arachnoid fluid  in  a  gouty  woman. 

Duckworth  admits  that  a  goitty  paraplegia  may  some- 
times occur  as  a  sudden  metastasis  from  a  joint,  and  that, 
although  it  may  be  complete  and  sphincterial,  some  cases 
may  recover.  Sometimes  the  attack  would  precede  the 
gouty  seizures. 

Practically  speaking,  Musgrave's  classification  of  the 
gouty  paralyses  and  nervous  affections  {apopUxia,  paralysis, 
vertigo,  etc.,  arthritica)  has  remained  unsupported  by 
anatomical  proof.  Nevertheless,  Sir  Willoughby  Wade 
has  lately  revived  Graves'  opinion  that  gouty  inflam- 
mation of  nerves  and  of  the  neurilemma  might  spread  up 
to  the  cord,  producing  softening  and  various  '  gouty 
paralyses.' 

A  gouty  neuritis  has  been  described  by  Dr.  Buzzard,  who 
strongly  urges  that  sodium  biurate  may  crystallize  in  the 
lymph  sheaths  of  nerves,  and  thus  set  up  the  motor,  sensory, 
and  vasomotor  symptoms,  and  the  neuralgise,  so  common 
in  gout,  and  which  Graves  had  long  since  attributed  to 
perineuritis.  As  a  working  theory  in  explanation  of  the 
clinical  nervous  phenomena,  this  view  possesses  practical 
importance. 

THE  MUSCLES. 

The  muscular  system  is  not  largely  involved  in  the 
clinical  history  of  gout,  although  rather  closely  concerned 
in  its  general  aetiology.  We  are  not  acquainted  with  any 
gouty  alterations  in  muscular  tissue,  though  uric  acid  has 
been  found  as  a  deposit  within  it  in  exceptional  cases, 
and  in  particular  in  the  myocardium.  The  uratic  infiltra- 
tion of  tendons  in  the  vicinity  of  joints  has  been  already 
described. 


V. 
THE  PATHOLOGY  OF  GOUT. 


CHAPTER  XVIII. 

URIC  ACID,  THE  LIVER,  THE  KIDNEY,  AND 
THE  NERVOUS  SYSTEM. 

URIC  ACID  IN  RELATION  TO  GOUT  AND  TO  ITS  LOCAL 

PHENOMENA. 

Since  the  prominent  place  occupied  by  uric  acid  in  the 
morbid  anatomy  of  the  coarse  lesions  of  chronic  gouty 
arthritis  and  tophi,  and,  in  a  less  degree,  of  acute  gouty 
arthritis,  has  been  fully  recognised,  a  similar  claim  has 
been  set  up  in  favour  of  its  connection  with  the  pathology 
of  gout  itself,  but  with  much  less  foundation  in  fact. 

Because  uric  acid  is  invariably  present  in  the  main 
lesions  of  gout,  and  at  times  present  in  excess  in  the  blood, 
and  because  it  is  apt  to  accumulate  in  enormous  quantities 
in  tophi,  we  should  not  hastily  take  it  for  granted  that  it 
is  the  essential  or  the  only  gouty  product.  Its  insolubility 
and  tendency  to  deposition  bring  it  before  our  notice ;  but 
it  is,  after  all,  but  one  product  in  a  complicated  chain  of 
metabolism.  Its  production  is  bound  up  with  that  of 
many  other  substances  of  which  we  have  taken  little  ac- 
count, and  the  relative  value  of  which  we  have  not  deter- 
mined, and  also  with  important  modifications  of  the  tissues. 


142  URIC  ACID  IN  RELATION  TO  GOUT 

if  there  is  any  truth  in  the  view  that  it  is  partly  a  product 
of  the  disintegration  of  the  latter. 

Concerning  the  local  manifestations  connected  with  a 
deposit  of  uric  acid  we  know  much — thanks  to  Sir  A. 
Garrod,  and,  more  recently,  to  Sir  W.  Roberts — but  we 
are  very  far  from  knowing  all.  We  are  still  ignorant 
whether  the  uratic  deposits  are  entirely  imported  into  the 
joints  or  in  part  produced  there  ;  whether  they  occur  in 
absolutely  healthy  cartilage,  or  only  after  previous  damage 
or  disease ;  whether  the  deposition  is  always  preceded  by 
a  degenerative  or  ulcerative  process,  as  suggested  by 
Ebstein  ;  or  whether  it  is  not  rather  the  cause  of  the 
irregularly  pitted  or  excavated  surface  of  the  cartilage. 
We  have  no  absolute  evidence  that  in  acute  arthritis  the 
acicular  deposit  is  the  cause  of  the  pain  and  of  the  inflam- 
mation ;  much  evidence  tends  in  another  direction.  We 
are  not  sure  to  what  extent,  as  suggested  by  Garrod,  and 
previously  by  Sydenham,  the  articular  attack  may  use  up 
any  previous  deposit,  and  thus  act  in  a  curative  manner. 
These  are  some  of  our  present  doubts  ;  and  they  concern 
the  local  aspect  of  gout,  which  is  by  far  the  easiest  of 
approach. 

Constittitional  gout  is  a  much  more  difficult  question  ;  and 
it  must  be  confessed  that  here  we  possess  nothing  more 
than  theories. 

1.  The  first  view  is  that  excess  of  uric  acid  is  the 
essence  of  gout,  and  that  the  excess  is  derived  from  nitro- 
genous food. 

2.  According  to  another  view,  uric  acid,  howsoever  pro- 
duced, is  not  necessarily  the  essence  of  constitutional  gout, 
yet  it  acts  as  the  catise  of  the  gouty  attack. 

3.  A  third  view  regards  uric  acid  as  resulting  from  the 
acute  gouty  arthritis,  or,  where  this  has  not  occurred,  from 
some  analogous  process. 


URIC  ACID  IN  RELATION  TO  GOUT  143 

4.  Lastly,  there  is  the  view  that  it  is  a  by-product  of  the 
intimate  changes  which  constitute  gout  ;  and  that  the 
results  connected  with  its  deposition  are,  to  a  great  extent, 
mechanical,  and  strictly  separate  from  the  original  patho- 
logical cause  of  gout. 

The  first  must  be  characterized  as  an  extreme  view, 
evolved  from  large  assumptions,  which  would  need  to  be 
carefully  examined  before  acceptance.  The  second  and 
third  are  open  in  part  to  the  same  objection,  but  they 
share  with  the  first  a  facility  for  explaining  the  temporary 
outbursts  of  gout  in  those  whose  intervening  health  is 
apparently  normal.  The  last  view  is  that  most  in  harmony 
with  the  notion  that  gout  is  a  disease  of  the  entire  organism, 
and  that  its  local  manifestations  are  governed  by  localizing 
circumstances  or  individual  peculiarities  of  tissue. 

We  still  hesitate,  then,  to  admit,  without  further  in- 
vestigation, that  gout  is  primarily  dependent  upon  uric 
acid  as  a  cause,  or  that  uric  acid  necessarily  exerts  any 
exclusive  influence  in  the  production  of  the  phenomena 
of  goutiness. 

THE  RENAL  THEORY. 

Among  the  great  pathological  problems  of  gout,  one  of 
the  most  puzzling  is  the  behaviour  of  the  kidney.  Has  it 
an  active  part  in  the  production  of  the  disease,  or  does 
it  only  feel  its  effects  ?  Two  circumstances  have  deprived 
us  of  an  easy  answer  :  our  ignorance  as  to  the  part  played 
in  health  by  the  kidney  in  connection  with  uric  acid  pro- 
duction and  excretion,  and  the  rarity  of  opportunities  of 
studying  the  pathological  anatomy  of  the  kidney  imme- 
diately before,  during,  and  immediately  after  the  attack. 
We  have  been  hitherto  dependent  upon  inferences,  and 
these  may  be  classified  as  anatomical  and  clinical. 

I.  Destructive  changes  of  greater  or  less  extent  are  the 


144  THE  RENAL  THEORY 

rule  in  chronic  gout,  as  elsewhere  dwelt  upon.  It  is,  how- 
ever, a  fact  of  primary  significance  that  the  rule  is  not 
absolute.  According  to  Sir  Dyce  Duckworth,*  '  It  is 
certain  that  gout  may  occur  in  the  ordinary  articular  form 
without  implicating  the  kidneys,  which  may  remain  sound 
even  in  old  age.  In  such  cases  there  is  usually  a  fine 
constitution,  great  resistance,  and  vigour  of  the  tissues, 
and  the  progress  of  the  disease  is  kept  at  bay  and  over- 
come by  the  vital  organs.'  In  primary  renal  gout  the 
general  health  is  poor,  and  a  progressive  cachexy  works 
its  special  ravages,  ending  life  prematurely. 

A  single  case  of  immunity  from  renal  disease  would  be 
enough  to  prove  that  renal  disease  is  not  a  si7ie  qua  non 
for  the  production  of  gout. 

From  the  other  side  of  the  question  arises  still  stronger 
evidence — gout  is  not  among  the  common  results  of  ex- 
tensive destruction  of  the  kidney.  The  field  of  observa- 
tion in  this  case  is  singularly  extensive.  It  need  hardly 
be  pointed  out  that  the  results  of  experimental  destruction 
of  the  kidney  in  healthy  animals  (Zalesky,  Ebstein,  and 
others)  cannot  be  adduced  as  elements  of  proof  in  connec- 
tion with  human  gout.  Anatomical  evidence  thus  favours 
the  conclusion  that  kidney  disease  is  not  responsible  for 
the  causation  of  gout. 

2.  Precisely  similar  inferences  are  the  outcome  of  clinical 
experience.  Sir  A.  Garrod's  original  observations  on  the 
urine  {loc.  cit.,  p.  133)  showed,  besides  a  relative  diminu- 
tion in  the  bulk  of  the  fluid,  that  during  the  early  stage  of 
an  attack  there  was  a  diminution  in  the  output  of  uric 
acid  (to  be  followed  by  an  increase  as  the  attack  passed 
off,  sufficient  in  some  cases  to  be  regarded  as  a  critical 
discharge),  whilst  the  amount  of  urea  remained  at  a  fair 
average.  Slight  albuminuria  may  also  occur^  but  it  is  not 
*  Loc.  ciL,  p.  1 01. 


THE  RENAL  THEORY  145 

common  in  the  first  attacks.  With  the  sole  exception, 
therefore,  of  concentrated  urine,  and  of  an  ephemeral 
diminution  of  uric  acid,  the  renal  function  is  normal, 
and  may,  under  favourable  circumstances,  remain  normal 
through  life  subsequently.  Sir  A.  Garrod's  theory  of  the 
causation  of  the  attack  being  based  on  this  single  devia- 
tion, it  is  right  to  mention  that  other  observers,  in  particular 
Lecorche,  -have  failed  to  find  any  diminution  in  the  amount 
of  urine  secreted,  or  in  the  quantity  of  uric  acid,  both  of 
which  are  stated  to  have  been  increased  in  some  cases. 

The  objection  that  the  diminished  uric  acid  excretion  is 
not  constant  in  gout,  is  met  by  the  statement  that  the  per- 
centage is  a  widely  fluctuating  one  in  health.  The  elaborate 
examinations  of  L.  Vogel  point  to  diminished  excretion.* 
Vogel,  in  three  cases  of  more  or  less  chronic  gout  with 
exacerbations,  in  which  food,  urine,  and  faeces  were  ex- 
amined, found  a  remarkable  nitrogen  retention,  much  in 
excess  of  that  belonging  to  the  uric  acid  retention.  The 
patients  behaved  in  this  respect  like  sufferers  from  renal 
disease,  although  the  clinical  signs  of  granular  kidney  were 
wanting. 

Absolute  retention  of  uric  acid  has  never  been  alleged ; 
but  with  excessive  production  from  any  cause,  the  filtering 
apparatus  may  be  rendered  incompetent,  and,  the  normal 
amount  being  excreted,  there  may  be  retention  of  the 
excess.  In  other  cases  renal  inadequacy  may  be  so  great 
as  to  accumulate  uric  acid  in  the  blood,  in  spite  of  a 
diminished  production. 

Levisonf  is  the  most  advanced  supporter  of  the  theory 
of  renal  inadequacy.  He  maintains  that  gout  cannot  be 
developed  without  a  primary  renal  lesion,  which  is  almost 

*  Zeitsch.  fur  Klin.  Med.,  xxiv.,  p.  512.     Quoted  by  Dr.  Archibald 
Garrod.     Cf.  Practitioner,  July,  1895. 

t  Quoted  by  Dr.  Archibald  Garrod,  loc.  cit. 

10 


146  THE  RENAL  THEORY 

invariably  interstitial.  Almost  every  autopsy  on  a  gouty 
patient  has  revealed  some  degree  of  lesion  ;  the  exceptions 
he  professes  to  explain.  In  a  series  of  forty-two  cases  of 
renal  disease,  examinations  were  made  of  the  great  toe  and 
other  joints.  In  twelve,  uratic  deposits  were  found,  and 
in  all  of  them  some  degree  of  granular  kidney  disease, 
whereas  in  thirty  cases  of  other  renal  diseases  no  trace  of 
uratic  deposit  was  detected.  He  believes  that  in  most 
instances  the  renal  change  long  preceded  the  gout. 

Levison  places  the  earliest  change  in  granular  kidney  in 
the  epithelium  of  the  convoluted  tubes,  the  interstitial 
change  being  secondary,  and  he  quotes  Oliver  and  others 
as  to  the  effect  of  lead.  It  has  been  shown  that  in  granular 
atrophy  the  uric  acid  excretion  is  diminished,  and  there  is 
an  accumulation  in  the  blood.  Levison  points  out  that 
albuminuria  is  not  constant  in  granular  kidney,  so  that  the 
absence  of  clinical  signs  during  years  of  apparent  health 
may  not  necessarily  imply  integrity  of  the  organ. 

Into  an  examination  of  these  conflicting  statements  it  is 
impossible  to  enter.  The  alleged  temporary  disturbance 
of  function  is  not  without  analogies.  Functional  albu- 
minuria is  a  type  of  temporary  abnormality  entirely  inde- 
pendent of  organic  disease.  It  would  be  rash,  however, 
to  state  that  this  disturbance  was  mainly  seated  in  the 
kidney ;  the  conditions  under  which  the  albumen  is  held 
in  the  blood  probably  have  the  greater  share  in  the  result. 

That  the  kidney  must  suffer  some  early  disturbance  from 
the  gouty  principles  ripening  for  an  outbreak  is  readily 
admitted  :  if  gout  has  attacked  one  cell  in  the  body  it 
has  attacked  them  all.  At  the  same  time,  circumstances 
point  to  a  preservation  of  the  functional  activity  of  the 
•organ  throughout  the  crisis.  In  cases  of  chronic  gout  the 
special  implication  of  the  kidney  is  easily  accounted  for. 
For  years  the  renal  epithelium  has  been  overstrained  in  its 


THE  RENAL  THEORY  147 

most  complex  department  of  work — that  of  nitrogenous 
excretion — and  in  its  most  trying  medium — the  strongly 
acid  medium ;  salts  of  uric  acid  have  crystallized  in  the 
organ,  and  become  irritating  foreign  bodies  : — serious  and 
varied  are  the  evil  consequences.  All  this,  however,  is  but 
the  late  result  of  the  gouty  state  of  which  we  seek  the 
cause,  and  can  hardly  be  adduced  as  throwing  light  upon 
the  latter. 

More  direct  evidence  is  needed  than  has  been  hitherto 
supplied  that  the  kidney  is  at  fault  in  the  first  instance, 
although  there. is  a  pleasing  simplicity  and  much  likelihood 
in  this  way  of  explaining  the  altered  proportions  of  uric 
acid  in  blood  and  in  urine. 

If  dependent  upon  the  kidney,  it  is  remarkable  that  this 
failure  of  excretion  should  be  limited  to  a  single  substance, 
and  that  it  should  so  quickly  be  replaced  in  some  instances 
by  the  opposite  state  of  increased  discharge.  '  The  acid  is 
thrown  out  in  much  larger  quantities  as  the  disease  is 
passing  off,  and  amounts  even  above  the  patient's  daily 
average  may  be  excreted,  forming  the  so-called  critical 
discharges.'*  Again,  in  speaking  of  some  cases  of  chronic 
gout,  Garrod  says,t  '  It  will  be  noticed  that,  although  the 
quantity  of  urea  remains  nearly  constant  and  normal,  the 
uric  acid  is  not  only  exceedingly  deficient,  but  subject  to 
the  greatest  fluctuations.' 

Since  in  all  these  cases  the  blood  contained,  presumably 
in  a  permanent  way,  much  uric  acid,  the  alleged  failure  of 
the  kidney  would  be  a  peculiarly  fitful  one,  and  in  that 
respect  unlike  the  behaviour  of  structural  disease. 

We  are  also  struck  by  the  fact  that,  whilst  no  morbid 

change  may  be  detected  in  the  kidney,  structural  changes 

are  going  on  elsewhere — in  the  joints  and  in  other  parts 

affected — which  we    must  admit  as   evidence   of  unseen 

*  Garrod,  loc.  cit.,  p.  133.  t  Loc.  at.,  p.  141. 


THE  RENAL  THEORY 


changes  taking  place  in  the  blood.  We  are  tempted  to 
correlate  the  disturbed  function  rather  with  these  manifest 
changes  than  with  an  organ  apparently  healthy,  fulfilling 
in  other  respects  its  normal  functions,  and  to  ask  whether 
the  uric  acid  may  not  be  rather  held  back  in  the  blood 
than  refused  passage  through  the  kidney.  Both  supposi- 
tions entail  subtle  influences  difficult  to  explain. 

Adopting  the  statement  of  Sir  A.  Garrod,  we  still  are 
left  to  infer  that  the  original  renal  disablement  is  partial 
only  and  evanescent,  and  we  must  conclude  that  the 
organic  affection,  if  present,  is  exceedingly  slight. 

An  absolute  demonstration  that  an  increase  of  uric  acid 
in  the  blood  and  its  diminution  in  the  urine  are  strictly 
simultaneous  events  would  remove  a  possible  source  of 
fallacy.  If  the  quantity  of  uric  acid  circulating  in  the 
blood  is  capable  of  variations  as  rapid  as  those  suggested 
by  Dr.  Haig's  observations,  the  want  of  agreement  in  the 
proportion  of  uric  acid  in  the  blood  and  of  that  in  the 
urine  might  be  more  apparent  than  real.  Sir  A.  Garrod's 
observations  appear  to  be  free  from  any  suspicion  of  errors 
of  this  kind. 

Sir  W.  Roberts  provides  us  with  an  ingenious  sugges- 
tion as  to  the  possible  nature  of  the  renal  defect. 

'  The  presence  of  uric  acid  in  mammalian  urine  might 
be  regarded  as  a  vestigial  phenomenon,'  evolution  having 
gradually  replaced  uric  acid  by  urea,  and  proportionately 
educated  the  urea-secreting  function,  whilst  the  uric-acid- 
secreting  function  was  progressively  undergoing  obso- 
lescence. Residuary  features  being  very  apt  to  vary  in 
individuals,  some  of  the  liability  to  gout  might  be  ex- 
plained by  an  unduly  marked  involution  of  the  function 
last  named.  Again,  the  two  functions  being  comple- 
mentary, family  gout  might  have  its  origin  in  the  over- 
worked state  of  the  urea-secreting  function  in  the  goutily 


THE  RENAL  THEORY  149- 

inclined  (who  are  generally  hearty  partakers  of  meat,  and 
therefore  produce  much  urea  as  well  as  some  uric  acid — 
as  I  to  15 — in  excess  of  the  normal).  'There  would  thus 
arise  a  persistent  demand  on  the  urea-excreting  faculty, 
which  could  only  be  satisfied  by  an  encroachment  on  the 
residuary  faculty  for  the  excretion  of  uric  acid.'* 

This  brilliant  attempt  to  bring  gout,  as  it  were,  within 
the  scheme  of  Darwinism  implies  also  a  recognition  of 
the  paramount  influence  of  individual  susceptibility,  con- 
sidered in  this  case  in  connection  with  the  kidney. 

If  without  uric  acid  there  is  no  gout,  the  way  in  which 
the  accumulation  takes  place  in  the  blood  is  more  than  a 
pathological  problem :  it  is  a  practical  one.  Sir  W.  Roberts 
does  not  pretend  to  offer  more  than  suggestions  on  this 
point,  believing  in  a  restricted  renal  capacity  for  uric  acid 
excretion  in  the  race,  and  in  a  special  restriction  in  some 
individuals.  Accumulation  would,  according  to  him,  begin 
with  the  overtaxing  of  the  kidney  with  nitrogenous  excre- 
tion. The  varying  factor  is  thus  the  degree  of  overwork 
of  the  kidney ;  slowly  the  arrears  of  uric  acid  would  creep 
up  till  extensive  accumulations  might  be  brought  about. 

The  chemical  history  of  the  phenomena  of  gout  as  told 
by  Sir  W.  Roberts  constitutes  a  complete,  a  consistent, 
and  an  adequate  theory,  which  possesses  over  all  others 
the  advantage  of  being  based  upon  facts  readily  demon- 
strated in  the  laboratory.  These  facts  are  a  great  and 
permanent  addition  to  our  knowledge  of  the  subject. 
They  shift  the  range  of  all  future  investigations  to  a  higher 
level,  and  give  them  a  novel  and  more  definite  direction. 
Indeed,  if  the  conclusions  to  which  they  lead  could  be 
applied  as  rigidly  to  the  case  of  living  subjects  as  they  are 
applicable  to  the  chemicals  used  in  the  test-tube,  we  might 
regard  the  problem  of  gout  as  completely  solved.  At 
*  Loc.  cit.,  p.  120. 


15°    ^^B  ^^^  RENAL  THEORY 

present  this  would  be  too  sanguine  a  view.  Their  dis- 
coverer is  the  first  to  acknowledge  that  these  conclusions 
cannot  at  present  be  transferred  to  clinical  ground  without 
some  reservations.  The  conditions  within  the  human 
body  have  none  of  that  simplicity  which  lessens  the  great 
difficulty  attaching  even  to  a  purely  chemical  investigation 
of  the  reactions  of  uric  acid  and  of  its  compounds.  Many 
factors  difficult  to  control  are  known  to  interfere  ;  and  we 
cannot  feel  certain  that  additional  factors  hitherto  un- 
suspected may  not  swell  their  number. 

To  what  extent  the  chemical  laws  so  admirably  demon- 
strated by  Sir  W.  Roberts  may  work  true  in  the  midst  of 
the  innumerable  reactions  complicating  those  in  which 
the  relatively  small  proportion  of  circulating  uric  acid 
is  immediately  concerned,  is  in  itself  a  matter  for  specula- 
tion. 

In  conclusion,  we  must  recognise  that  in  the  result  the 
kidney  is  inadequate  to  the  circumstances ;  nevertheless, 
the  change  may  be  in  the  circumstances  rather  than  in  the 
kidney. 

We  still  need  a  proof  that  the  kidney  is  primarily  at 
fault.  After  all,  the  kidney  is  but  the  door  out  of  the 
house,  a  humble  function  compared  with  the  multifarious 
activities  astir  within.  May  not  the  uric  acid,  instead 
of  being  in  the  ordinary  sense  locked  in,  be  detained  or 
attracted  by  serum  or  cells,  just  as  a  powerful  magnet 
placed  in  the  centre  of  a  stream  might  withhold  metallic 
particles  from  the  influence  of  the  current  which  hitherto 
had  over  them  an  undivided  control  ? 

THE  LIVER  IN  GOUT. 

If  gout  can  be  correctly  viewed  as  a  disease  of  nutrition 
(and  its  intimate  connection  with  the  alimentary  function 


THE  LIVER  IN  GOUT  151 

none  would  doubt),  the  liver,  must  have  a  place  in  its 
evolution.  The  clinical  importance  attaching  to  hepatic 
disorders  is  well  known,  in  spite  of  the  meagre  data 
furnished  by  pathology.  Whilst  it  is  no  less  free  than 
the  kidney  from  any  pre-existing  structural  disease  capable 
of  originating  gout,  we  have  various  reasons  for  suspecting 
that  the  liver  may  take  a  large  share  in  the  manufacture 
of  the  affection ;  they  are  all  connected  with  its  activity 
as  the  great  central  chemical  workshop  of  the  organism. 

The  Etiological  Place  of  the  Liver  in  Gout. — To  say  that 
the  liver  is  concerned  in  the  production  of  gout  is,  in  a 
certain  sense,  a  safe  proposition.  Its  varied  functions 
cannot  all  be  entirely  foreign  to  the  disturbance.  To 
allege  that  it  was  mainly  at  fault  in  the  mode  of  disposing 
of  the  nitrogenous  surplus  would  be  to  ignore  other  func- 
tional defects  of  equal  importance.  Some  solidarity  must 
exist  between  the  various  activities  of  the  hepatic  cell,  and 
their  joint  implication  is  almost  inevitable. 

The  precise  position  occupied  by  the  liver  in  the  aetiology 
of  gout  must  remain  doubtful,  in  connection  with  the 
extent  of  the  physiological  hepatic  duties,  with  the  re- 
markable tolerance  of  the  organ  in  some  directions,  and 
with  its  multiple  opportunities  of  going  wrong.  Again, 
for  long  periods  its  failures  and  shortcomings  may  re- 
main latent.  They  neither  affect  structure,  nor  do  they 
necessarily  lead  to  perceptible  changes  in  aspect ;  but 
meanwhile  they  may  be  reflected  in  states  of  the  system. 

By  the  side  of  these  latent,  invisible  hepatic  delin- 
quencies, there  are  those  which  are  more  obvious.  In  a 
given  proportion  of  gouty  patients,  we  are  struck  by  the 
hepatic  or  bilious  look,  and  we  are  led  to  inquire  whether 
in  them  the  liver  may  not  be  the  prime  offender.  If 
in  them,  may  it  not  also  exercise  in  others  an  setiological 
influence  not  less  real,  though  less  manifest  ? 


152  THE  LIVER  IN  GOUT 

We  are  reminded  that  gout  affects  all  constitutions,  and 
among  them  the  bilious,  in  whom  a  due  proportion  is  at 
times  lost  between  the  secretion,  the  excretion,  and  the 
feabsorption  of  bile,  and  who  are  often,  moreover,  the 
subjects  of  functional  nervous  disturbances  or  nerve- 
storms.  It  is  more  than  probable  that  the  hepatic 
inadequacy  is  not  in  them  limited  to  the  biliary  function, 
but  extends  to  other  aspects  of  hepatic  metabolism. 
Again,  Murchison's  lithsemia  may  obtain  in  those  whose 
biliary  function  is  not  obviously  at  fault.  It  is  idle,  how- 
ever, in  view  of  the  prevalent  freedom  of  gouty  subjects 
from  biliousness  and  from  lithsemia,  to  attempt  to 
generalize  from  the  peculiarities  of  these  limited  classes, 
and  to  refer  the  aetiology  of  gout  to  antecedent  hepatic 
defect.  We  must  be  content  to  infer  that  the  liver  may 
take  in  the  general  nutritional  changes  which  are  pro- 
bably bound  up  with  goutiness,  a  share  commensurate 
with  its  leading  position  in  normal  metabolism. 

THE  NERVOUS  SYSTEM  IN  GOUT. 

The  Influence  of  the  Nervous  System  in  the  Production  of 
Gout. — The  nervous  system  takes  a  leading  share  in  the 
history  of  gout,  and  in  the  mechanism  of  many  of  its 
visceral  irregularities ;  but  as  soon  as  we  attempt  to 
formulate  its  status  as  a  supposed  primary  cause,  we  dis- 
cover the  vicious  circle  of  the  argument.  We  are  thwarted 
at  starting  for  want  of  working  material.  Of  anatomical 
evidence  the  lack  is  absolute.  The  clinical  supply  is 
abundant,  but  of  the  wrong  kind,  intangible,  imponder- 
able, and  useless  for  accurate  inference  or  deduction. 
Until  some  independent  alteration  in  the  nervous  centres 
can  be  demonstrated,  we  must  regard  them  as  also  suffer- 
ing with  the  rest  from  the  pervading  perversion  of  nutrition. 


THE  NERVOUS  SYSTEM  IN  GOUT  153 

Their  directing  power  in  the  causation  of  gouty  phenomena 
is  borrowed.  Behind  them  is  the  real  cause,  which  from 
its  ubiquitous  action  throughout  the  system  we  are  bound 
to  identify  with  the  juices.  At  the  present  stage,  we  still 
are  unable  to  construct  a  nervous  theory  of  gout  on  strictly 
pathological  lines.  We  are  restricted  to  the  observation 
and  to  the  discussion  of  the  nervous  phenomena  witnessed 
in  the  gouty,  and  the  range  of  our  disquisitions  is  exclusively 
clinical. 


CHAPTER  XIX. 
THE  MORBID  AFFINITIES  OF  GOUT. 

GOUT  AND  RHEUMATISM. 

We  cannot  fail  to  learn  from  a  critical  comparison  between 
the  two  affections,  the  symptoms  of  which  are  so  familiar 
and  the  causes  so  obscure. 

j^tiologically  they  belong  to  different  ages.  In  the 
young,  articular  rheumatism,  so  long  overlooked,  is  now 
recognised  as  common,  and  as  capable  of  varied  manifes- 
tations.    In  old  age  it  is  rare. 

Gout  is  decidedly  uncommon  before  middle  age,  though 
sometimes  seen  as  early  as  twenty,  and  exceptionally  in 
childhood. 

In  common  the  two  diseases  possess  the  feature  of 
heredity,  though  this  is  more  prominent  in  gout  than  in 
rheumatism.  In  rheumatism,  Sir  A.  Garrod  found  a 
hereditary  predisposition  in  about  25  per  cent. ;  Fuller 
in  27  per  cent. ;  Chomel  in  33  per  cent.  ;  and  Dr.  Archi- 
bald Garrod  in  from  30  to  35  per  cent.  In  gout  more  than 
50  per  cent,  of  Sir  A.  Garrod's  cases  gave  a  hereditary 
history. 

It  is  well  known  that  in  the  individual  an  early  liability 
to  attacks  of  rheumatism  is  often  followed  by  a  gouty  old 
age.  Again,  in  both  cases  a  first  attack  does  not  protect 
the  subject,  but  strongly  predisposes  to  a  recurrence.  In 
this  country  both  diseases  are  largely  prevalent  ;  but  the 
same  parallelism  is  not  found  elsewhere. 


GOUT  AND  RHEUMATISM  155 

In  both  there  is  a  disproportion  between  the  sexes,  in 
favour  of  frequency  in  the  male  ;  but  the  two  diseases 
present  a  striking  difference,  gout  being,  according  to 
Fagge  and  Pye  Smith,  eight  or  nine  times  more  frequent 
in  men  than  in  women,  whereas  the  Collective  Investiga- 
tion Committee  '*  found  among  654  cases  375  males  and 
279  females. 

Pathology. — Whilst  our  ignorance  as  to  the  nature  of 
the  poison  of  rheumatic  fever  is  almost  absolute,  we  know 
that  in  gout  uric  acid  is  in  excess.  Whether  the  theory 
which  regards  lactic  acid  as  the  rheumatic  poison  be 
ultimately  proved  correct  or  not,  we  recognise  in  rheumatic 
fever  a  greater  resistance  to  the  alkalizing  effect  of  alkalies 
than  in  average  subjects  of  gout,  and  a  greater  over-pro- 
duction of  acid.  Dr.  Haig  does  not  hesitate  to  pronounce 
this  to  be  uric  acid ;  and  he  adduces  arguments  in  favour 
of  a  conclusion  that  rheumatic  fever  and  gout  are  different 
utterances  of  one  and  the  same  malady,  or  at  any  rate 
diverging  results  from  the  same  cause.  Some  of  the 
reasons  for  withholding  assent  from  this  view  will  be 
given  presently. 

Clinical  Pathology. — The  clinical  features  of  the  two 
diseases  present  striking  differences.  The  joint  affection 
in  rheumatism  is  typically  polyarticular,  in  gout  at  first 
monarticular.  The  chronic  attenuations  of  gouty  arthritis 
tend  to  become  more  and  more  generalized  in  the  body ; 
those  of  rheumatism  to  be  more  and  more  localized. 

In  both  diseases  the  agencies  which  determine  the 
implication  of  the  several  joints  are  obscure,  though 
not  equally  so.  When,  in  a  bed-ridden  acute  rheumatic 
case,  the  pain  is  transferred  from  the  right  knee  to  the 
left  elbow,  or  to  any  other  joint,  we  cannot  successfully 
argue  that  the  locality  of  the  metastasis  has  been  deter- 
*  Briy.  Med.  Journ.,  February  25,  1888. 


1,56  GOUT  AND  RHEUMATISM 

mined  by  any  external  influence.  In  the  local  incidence 
of  gout  very  definite  factors  may  often  be  found.  Above 
all,  there  is  the  unaccountable  but  systematic  regularity 
with  which,  in  the  large  majority  of  cases,  the  great 
toe  is  attacked  first.  In  exceptional  instances  this  rule  is 
departed  from,  and  the  influence  of  localizing  causes  may 
be  demonstrated. 

Thus,  in  a  man  confined  to  his  bed  with  hemiplegia,  the 
leg  recovering  quickly  and  the  arm  remaining  paralyzed, 
gout  may  develop  in  the  paralyzed  hand.  Again,  local 
injury  to  a  joint  will  often  determine  a  gouty  attack  in 
that  joint.  In  both  these  apparently  opposite  instances 
it  is  impossible  not  to  trace  a  nervous  influence,  though 
views  may  differ  as  to  the  exact  relation  which  this  bears 
to  the  local  mischief.  Sydenham's  classical  observations 
on  the  efficacy  of  study  in  promoting  a  return  of  his  gouty 
troubles  supply  another  example  of  the  connection  to  be 
traced  between  nervous  agencies  and  gout. 

In  rheumatism,  though  the  most  used  joint,  or  the 
injured  joint,  may  sometimes  suffer  first,  and  though 
nervous  fatigue  may  predispose,  nothing  comparable  to 
the  reactions  described  can  be  said  to  occur. 

The  joints  affected  present  a  very  different  history.  In 
all  uncomplicated  cases  acute  rheumatism  passes  away 
and  leaves  the  joint  absolutely  unchanged.  With  gout 
the  restitutio  ad  integrum  is  apparent  only ;  the  cartilage 
bears  a  lasting  trace  of  the  specific  inflammation.  To 
this  all-important  distinction  we  shall  presently  revert. 

The  blood,  which  has  been  shown  by  Dr.  Archibald 
Garrod  to  be  so  profoundly  affected  in  rheumatism,  pre- 
sents no  corresponding  changes  in  gout. 

The  action  of  remedies,  as  at  present  employed,  establishes 
a  strong  contrast  between  the  two  diseases.  Although 
rare  instances  are  recorded  of  the  prompt  disappearance 


GOUT  AND  RHEUMATISM  157 

and  apparent  cure  of  the  acute  gouty  trouble,  an  abrupt 
cessation  of  the  local  inflammation  is  usually  ominous  of 
graver  mischief  about  to  arise  elsewhere.  In  rheumatism 
we  are  now  familiar  with  the  rapid  relief,  under  the  in- 
fluence of  salicylates,  of  all  the  parts  affected,  without  any 
recurrence  in  the  other  joints  or  any  implication  of  the 
viscera. 

Although  this  is  but  a  fragmentary  sketch  of  the  features 
of  likeness  and  of  contrast  of  the  two  diseases,  we  may 
venture  to  draw  from  them  provisional  conclusions. 

The  differences  are  so  great  that,  were  they  considered 
alone,  the  affections  must  be  pronounced  essentially  dis- 
similar. Do  the  points  of  resemblance  avail  to  modify  this 
verdict  ?  They  do  not  argue  much  more  than  an  identity 
in  some  of  the  structures  involved.  In  both  diseases  the 
inflammation  is  thrown  upon  the  joints  and  their  fibrous 
surroundings ;  and  in  both  the  irritant  is  in  great  part 
extravascular  and  intralymphatic.  A  certain  similarity 
must  be  expected  in  the  reactions  obtained  from  the  self- 
same tissues,  even  when  arising  from  irritations  essentially 
distinct. 

The  dissimilarities  existing  between  the  irritating  agents 
are  not  difficult  to  trace : 

1.  In  gout,  a  solid  residue  is  almost  invariably  left  by 
the  attack ;  in  rheumatism,  nothing  is  left  behind  which 
even  the  microscope  can  detect,  and  during  the  seizure 
itself  the  anatomical  changes  are  merely  such  as  cells 
must  undergo  in  any  common  severe  inflammation.  The 
irritant  must  be  either  a  fluid,  or,  if  a  sohd,  one  so  subtle 
as  to  escape  our  present  means  of  investigation. 

2.  The  same  conclusion  is  derived  from  the  prevailing 
non-metastatic  tendency  of  gout,  and  by  the  opposite 
tendency  in  rheumatism.  The  irritant  in  gout,  though 
conveyed  by  the  blood,  is  irritant  only  in  its  extravascular 


.158  GOUT  AND  RHEUMATISM  - 

phase.  In  rheumatism,  whilst  it  is  extravascular  in  its 
arthritic  manifestations,  the  irritant  circulates  in  an  active 
state  both  in  the  lymphatic  and  in  the  blood  stream. 
Hence  gout  leads  to  deposition  within  the  cardiac  wall  ; 
but  rheumatism  will  profoundly  affect  the  endocardial 
membrane  and  the  blood  itself,  and  rheumatic  metastasis 
is  probably  but  the  expression  of  its  ubiquitous  presence 
within  the  latter. 

Are  Gout  and  Rheumatism  capable  of  blending  ? — The 
question  as  to  a  possible  association  between  gout  and 
rheumatism  has  never  been  set  at  rest.  There  are  still 
those  who  believe  in  an  arthritic  diathesis  equally  pre- 
disposing to  either,  the  event  being  determined  in  each 
instance  by  the  special  circumstances  of  the  attack. 
Charcot  held  this  view ;  Dr.  Haig  is  strongly  of  that 
opinion ;  and  the  same  tendency  of  thought  is  expressed 
in  Mr.  J.  Hutchinson's  words* :  '  Gout  is  but  rarely  of 
pure  breed,  and  often  a  complication  of  rheumatism.  It 
so  often  mixes  itself  up  with  rheumatism,  and  the  two  in 
hereditary  transmission  become  so  intimately  united,  that 
it  is  a  matter  of  considerable  difficulty  to  ascertain  how  far 
rheumatism  pure  can  go.  ...  It  is  to  this  permanent 
modification  of  tissue  that  the  peculiarities  in  the  process 
(transitory  rheumatic  pains  in  joints,  fasciae,  and  muscles, 
chronic  crippling  arthritis,  destructive  arthritis  with 
eburnation,  lumbago,  sciatica)  are  due.' 

Clinically,  this  view  seeks  support  in  the  fact  that  some 
gouty  subjects  not  infrequently  have  suffered  from  acute 
rheumatic  attacks.  An  opposite  argument,  however,  might 
be  based  upon  this.  The  tendency  of  rheumatism  and  the 
tendency  of  gout  to  recur  being  so  great,  the  sudden 
appearance  of  genuine  gout  in  one  known  to  be  rheumatic, 
instead  of  a  rheumatic  or  even  of  a  modified  rheumatic 
*  *  Pedigree  of  Disease,'  1883,  p.  126,  quoted  by  Duckworth. 


GOUr  AND  OSTEO-ARTHRITIS  159 


attack,  goes  far  to  suggest  a  radical  difference  between 
the  two  complaints,  although  in  some  of  their  symptoms 
they  overlap,  and  in  their  imperfectly  developed  phases 
they  may  be  difficult  to  diagnose. 

GOUT  AND  OSTEO-ARTHRITIS. 

The  relation  between  gout  and  rheumatoid  arthritis  is 
one  of  the  most  vexed  questions  of  modern  pathology. 
Its  discussion  cannot  be  attempted  in  these  pages,  and  the 
reader  must  be  referred  for  a  complete  study  of  the  sub- 
ject to  Sir  Dyce  Duckworth's  treatise  on  gout,  and  to 
Dr.  Archibald  Garrod's  treatise  on  rheumatism.  The 
writer's  views  may  be  expressed  in  a  very  few  lines. 

Of  the  existence  of  a  disease  entailing  permanent 
articular  damage  and  deformity,  and  essentially  differing 
from  gout  and  from  rheumatism,  sufficient  evidence  seems 
to  be  afforded  both  by  the  anatomical  appearances  and  by 
the  clinical  phenomena. 

Anatomically,  its  feature  is  a  hyperplasia  of  cartilage,  a 
change  ultimately  tending  on  the  one  hand  to  destructive 
softening,  and  to  ossification  on  the  other — and  a  hyper- 
plasia of  bone,  a  change  tending  to  thickening  and  con- 
densation of  the  bony  constituents  of  the  joints.  In  its 
extreme  developments  the  disease  would  thus  lead  to  the 
disappearance  of  a  great  part  of  the  articular  cartilage,  and 
to  an  extensive  formation  and  condensation  of  bone. 

Inasmuch  as  each  of  these  two  concurrent  changes  may 
be  variously  active,  different  lesions  and  different  types  of 
disease  will  arise.  All  types,  however  (excluding  only 
malum  coxce  senile,  which  may  be  an  altogether  different 
aifection),  present  well-marked  features  in  common,  the 
most  striking  of  which  is  the  symmetry  of  the  lesion,  a 
peculiarity  alike  foreign  to  rheumatism  and  to  gout  in  its 
earlier  manifestations. 


i6o  GOUT  AND  OSTEO-ARTHRITIS 

Clinically,  not  this  alone,  but  many  other  circumstances, 
support  the  view  set  forth  by  Dr.  Ord,  and  largely  enter- 
tained, that  the  affection  is  essentially  conditioned  by 
disturbed  nerve  agencies,  whether  viscero-reflex,  or  in 
connection  with  spinal  or  medullary  centres  or  with 
an  assumed  trophic  'joint  centre'  in  the  vicinity  of  the 
vagus  centre. 

The  disease  affects  individuals  of  widely  different  tem- 
perament and  of  various  ages.  The  assumption  of  a 
prevailing  nervous  mechanism  does  not  exclude  the 
possible  incidence  of  humoral  influences.  In  the  writer's 
opinion,  based  upon  some  observation,  the  disease  may 
occur,  and  in  younger  women  it  often  occurs,  in  a  pure 
unmixed  form,  or  it  may  affect  those  eminently  rheu- 
matic, or,  lastly,  those  prone  to  gout  or  actually  gouty. 
In  practice  he  has  met  with  '  simple  rheumatoid  arthritis,' 
with  '  rheumatic  rheumatoid  arthritis,'  and  with  '  gouty 
rheumatoid  arthritis,'  and  the  treatment  has  varied  with 
the  special  form  under  observation. 

Reverting  now  to  the  original  question,  the  rheumatoid 
arthritis  of  the  gouty  may  closely  simulate  genuine  gout  in 
its  chronic  form,  which  is  often  polyarticular,  and  may  be 
symmetrical.  Some  of  the  lesions  found  in  the  one  are 
apt  to  occur  in  the  other.  The  lipping  of  rheumatoid 
arthritis  may  also  occur  in  gouty  joints.  Heberden's 
nodules,  so  common  in  gout,  were  supposed  by  their  dis- 
coverer to  be  limited  to  rheumatoid  arthritis.  The 
deformities  due  to  the  two  diseases  may  present  a  con- 
siderable outward  resemblance.  The  clinical  history  of 
the  patient  often  fails  to  point  to  a  distinction,  so  many 
gouty  patients,  especially  women,  presenting  no  acute 
monarticular  seizure  at  the  onset.  It  has  often  happened 
that  cases  have  been  mistaken,  and  this  has  added  to  the 
previous  confusion.  .  . 


GOUT  AND  OSTEO-ARTHRITIS  i6i 

In  this  country,  where  gout  is  so  prevalent,  not  a  few 
cases  of  rheumatoid  arthritis  are  Hable  to  gouty  compHca- 
tions,  partly,  doubtless,  under  the  influence  of  gouty 
heredity,  which  appears,  though  this  point  needs  elucida- 
tion, to  favour  the  advent  of  osteo-arthritis. 

The  coexistence  with  gouty  deposits  of  changes  re- 
sembling osteo-arthritis  led  Fuller*  and  Hutchinson  to 
believe  in  a  blending  of  the  rheumatoid  with  the  gouty 
element — at  least  in  some  cases.  This  is  the  view  also 
taken  by  the  writer.  Mixed  forms  may  arise  in  which  the 
osteo-arthritic  changes  are  conspicuous,  and  uratic  incrus- 
tations may  also  have  occurred.  This  in  no  way  in- 
validates the  statement  as  to  the  independent  character  of 
the  two  diseases  ;  indeed,  their  dualism  always  asserts 
itself  either  clinically  or  in  their  anatomical  appearances. 

GOUT  AND  PHTHISIS. 

Between  the  prevalence  of  rheumatism  and  of  phthisis 
there  is  something  more  than  the  link  established  by  the 
identity  of  the  climatic  factors,  which  in  this  country 
favours  them  both.  Dr.  James  Edward  Pollockf  has  given 
well-known  proof  of  the  frequency  of  this  association. 

The  association  with  gout  is  much  less  often  seen,  nor 
was  it  to  have  been  expected.  Sir  Dyce  Duckworth^ 
quotes  the  view  held  by  Noel  Gueneau  de  Mussy,  that  the 
arthritic  and  the  tubercular  constitutions  are  so  far  con- 
vertible as  to  be  apt  to  alternate  in  their  hereditary  trans- 
mission, and  that  in  the  history  of  a  gouty  descendance  the 
immunity  of  an  intermediate,  whilst  not  absolute  as  regards 
gout  itself,  might  be  tainted  with  marked  tubercular  or 
scrofulous    manifestations.     Sir   James    Paget's    view    is 

*  'Rheumatism,  Rheumatic  Gout  and  Sciatica  ;'  1852. 

f  '  Elements  of  Prognosis  in  Consumption  ;'  London,  1865. 

X  Loc.  at.,  p.  172. 

II 


i62  GOUT  AND  PHTHISIS 

also  quoted,  showing  the  intermixture  in  individuals  by 
inheritance  of  the  gouty  and  of  the  scrofulous  constitu- 
tion, each  of  which  may  assert  itself,  not  only  separately 
at  the  ages  relatively  obnoxious  to  each,  but  in  combina- 
tion with  the  other.  Thus,  the  arthritis  of  gout  may  be 
modified  by  inherent  scrofulous  tendency,  and  assume  a 
more  chronic  and  destructive  type.  On  the  other  hand, 
the  phthisis  of  middle  age,  which,  unlike  the  early  scrofula 
of  childhood,  may  come  within  the  range  of  an  active 
gouty  influence,  has  long  been  known  to  be  mitigated  by 
the  association  in  question.  An  arthritic  or  gouty  form 
of  phthisis  was  formerly  described,  and  even  Laycock 
recognised  an  '  arthritic  tubercular  cachexia.' 

Sir  Andrew  Clark  has  shown  that  the  senile  cases 
characterized  by  copious  haemorrhage,  by  dyspnoea,  by 
immoderate  cough  and  expectoration,  and  by  ultimate 
recovery  when  the  haemorrhage  itself  is  not  fatal,  are  not 
cases  of  phthisis,  but  of  emphysema.* 

Putting  aside  such  cases,  evidence  is  found,  as  shown 
by  Dr.  Pollock,  that  in  genuine  phthisis  the  advent  of 
gout  is  in  a  measure  protective,  and  favours  a  chronic 
mild  type.  To  this  view  Sir  Dyce  Duckworth  adds  his 
testimony,  believing  that  the  modifying  effect  of  gout  is 
perceptible  in  two  directions  : 

1.  In  more  than  the  usual  tendency  to  initial  and  to 
recurrent  haemoptysis ;  and 

2.  In  a  marked  tendency  to  cicatrization,  in  spite  of 
gouty  acerbations  of  the  articular  process. 

He  also  reminds  us  of  another  well-known  form  of  the 
association.  The  phthisis,  which  sometimes  supervenes 
at  a  late  stage  of  chronic  gout,  may  benefit  from  the 
gouty  hereditary  influence  which  may  still  linger  in  the 
economy.     But,   in  other  cases,   the  existence  of  a  pro- 

*  C/.  p.  130. 


GOUT  AND  CANCER— GOUT  AND  OBESITY  163 

found  gouty   cachexia  may  assist,   at  any  rate  does  not 
materially  delay,  the  destructive  changes  in  the  lung. 

GOUT  AND  CANCER. 
The  connection  between  gout  and  cancer  needs  further 
study.  That  the  two  diseases  should  frequently  coincide 
is  natural,  as  they  are  liabilities  of  the  same  period  of  life. 
Various  writers  have  expressed  their  belief  in  a  more  direct 
relationship.  Sir  Dyce  Duckworth,  who  has  examined  the 
evidence  of  this  alleged  connection,  is  not  impressed  with 
the  existence  of  any  proof  of  an  arthritic  predisposition 
to  cancer. 

GOUT  AND  OBESITY. 

The  conjunction  of  these  two  names  under  one  title  is 
not  meant  to  imply  a  necessary  association  or  any  intimate 
pathological  connection  between  gout  and  obesity.  So 
far  from  being  identical,  they  only  wear  that  '  family  air ' 
which  strikes  us  most  in  brothers  who  happen  to  be  in 
every  line  of  feature  most  different.  In  spite  of  that  lack 
of  direct  resemblance,  kinship  exists  between  the  two 
affections,  often  plainly  to  be  traced,  though  we  should 
not  attach  too  great  an  importance  to  this  circumstance. 

Reference  has  already  been  made  to  Scudamore's  tables 
of  frequency  of  obesity  in  the  gouty.  Bouchard*  has 
devoted  special  attention  to  the  whole  subject,  which 
should  be  read  in  his  interesting  pages.  In  94  cases, 
observed  presumably  in  France,  where  gout  is  less  common, 
Bouchard  found  gouty  antecedents  in  28,  and  rheumatic 
in  33.  In  a  majority  of  the  remainder  of  his  cases  migraine, 
diabetes,  lithiasis  (renal  and  biliary),  eczema,  and  neuralgia 
gave  evidence  of  an  '  arthritic  '  habit.f 

*  '  Maladies  par  Ralentissement  de  la  Nutrition.' 
t  C/.  Duckworth,  loc.  a'l.,  p.  195. 


1 64  GOUT  AND  OBESITY 

Early  obesity  occurs  in  gouty  families,  rather  commonly 
in  the  Hebrew  race,  and  it  is  often  associated  with  gravel. 

Obesity  with  glycosuria  is  also  a  gouty  conjunction,  and 
the  term  '  fat  diabetes  '  points  to  this  connection.  Duck- 
worth states  that  occasionally  fat  diabetics  gradually 
become  lean  diabetics,  and  he  also  notes  that  obesity 
may  long  precede  glycosuria. 

It  is  in  the  treatment  and  management  of  gout  and  of 
obesity  that  their  resemblance  stands  out  most  clearly. 
These  affections  are  primarily  and  essentially  dietetic  ; 
their  treatment  is  based  upon  retrenchment,  for  in  both 
alike  there  is  a  surplus  of  nutrition.  The  gouty  and  the 
corpulent,  not  only  in  some  aspects  of  their  disease,  but 
in  the  details  of  its  cure,  are  apt  to  be  fellow-sufferers. 

It  is  unnecessary  to  dwell  upon  the  other  constitutional 
diseases.  Syphilis,  when  it  happens  to  complicate  gout, 
gives  rise  to  peculiarities  in  the  clinical  symptoms  to  which 
Mr.  J.  Hutchinson  has  invited  further  attention.  The 
combination  in  question  has  not  hitherto  thrown  fresh 
light  upon  the  pathology  of  gout. 

Struma  is  among  the  recognised  kinship  of  gout. 
Charcot*  has  shown  that  the  several  members  of  the  same 
family  may  suffer  individually  from  gout,  scrofula,  diabetes, 
and  obesity.  The  relation  between  gout  and  struma  in 
hereditary  transmission  is  a  matter  of  frequent  observation 
in  practice. 

GOUTY  GLYCOSURIA,  AND  DIABETES. 

The  pathology  of  gouty  diabetes  and  glycosuria  is,  if 
it  were  possible,  even  more  puzzling  than  that  of  the 
uncomplicated  conditions.    The  whole  subject  is  at  present 

*  '  LcQons  sur  les  Maladies  des  Vieillards  et  les  Maladies  Chroniques, 
p.  98  ;  Paris,  1868.     Quoted  by  Duckworth. 


GOUTY  GLYCOSURIA  AND  DIABETES  165 

an  almost  exclusively  clinical  study  ;  nevertheless,  like  the 
equally  obscure  subject  of  lead-gout,  it  is  fertile  in  sugges- 
tions. 

We  must  forbear  entering  into  clinical  details,  and 
merely  state  in  the  shape  of  propositions  the  recognised 
results  of  clinical  experience  : 

1.  The  genuineness  of  a  gouty  connection  in  many  cases 
of  temporary  glycosuria  is  proved  beyond  doubt ;  this  is 
also  true  of  some  cases  of  diabetes.* 

2.  The  intermittent  glycosuria  of  elderly  and  obese 
persons,  which  has  been  regarded  as  a  simple  result  of 
digestive  inadequacy,  is  more  common  in  gouty  subjects 
than  in  others,  and  in  them  is  more  prone  to  pass  into  a 
permanent  diabetes.  Diabetes  originating  early  in  life 
is  sometimes  observed  in  the  descendants  of  gouty  persons. 

3.  Diabetes  originating  late  in  gout  is  specially  mild  in 
type,  slowly  progressive,  liable  to  fluctuations,  and  even 
compatible  with  longevity.  A  proportion  of  the  sufferers 
are  obese,  many  present  for  a  time  the  florid  complexion 
and  full  habit  of  relatively  robust  health.  Neither  the 
diuresis  nor  the  wasting  which  characterize  the  progress 
of  diabetes  when  due  to  other  causes  is  a  prominent 
feature  of  this  variety.  The  daily  amount  of  urine  may 
hardly  exceed  a  full  normal  average. 

4.  Gouty  glycosuria  often  alternates  in  the  individual 
with  other  visceral  manifestations  of  gout,  and  particularly 
with  the  neuralgise  and  the  visceral  neuroses,  and  with 
gravel.     Gravel  sometimes  coincides  with  the  glycosuria  ; 

*  A  historical  review  of  the  growth  of  our  clinical  knowledge  on 
this  point  is  given  by  Sir  Dyce  Duckworth  (loc.  czf.,  p.  178),  who  quotes 
the  opinions  of  Willis  (1674),  Trotter  (1788),  Stosch  (1828),  Naumann 
(1829),  Prout  (1843),  Bence  Jones  (1853),  Gairdner  (1854),  Claude 
Bernard  (1855),  Laycock  (1862),  Marchal  de  Calvi  (1864),  Charcot 
(1868),  Garrod,  Roberts,  Dickinson,  Ord,  Brunton,  Lecorchd,  Lan- 
cereaux,  Las^gue,  R.  Schmitz,  and  others. 


1 66  GOUTY  GLYCOSURIA  AND  DIABETES 

its  absence  in  most  of  the  cases  may  be  explained  as  a 
result  of  the  diuresis. 

5.  The  same  explanation  has  been  applied  by  Garrod  to 
the  prevailing  dissociation  between  the  glycosuria  and  the 
articular  attacks.  With  the  exception  of  a  shght  and 
ephemeral  glycosuria  which  may  accompany  acute  gout, 
the  appearance  of  sugar  in  the  urine  usually  coincides  with 
a  remission  of  the  gouty  manifestations.  This  fact  has 
probably  suggested  the  belief  formerly  entertained  in  a 
direct  antagonism  between  gout  and  diabetes. 

Much  pathological  speculation  has  arisen  from  a  con- 
sideration of  these  and  of  many  other  minor  peculiarities 
of  the  affection  under  review.  The  intermittence  of  the 
glycosuria,  and  sometimes  even  of  the  diabetes,  warrants 
at  least  one  conclusion,  viz.,  that,  at  any  rate  in  its 
beginnings,  gouty  diabetes  is  a  functional  rather  than  an 
organic  disorder.  Opinions  are  almost  unanimous  in  favour 
of  the  liver  as  the  seat  of  the  disturbance,  but  as  to  the 
mode  of  origin,  and  as  to  the  mechanism  of  the  latter,  they 
diverge.  From  the  standpoint  of  gout  two  views  present 
most  interest.  The  hepatic  disorder  is  variously  held  to 
be  primary,  or  to  be  induced  by  nervous  agencies.  The 
supporters  of  both  these  theories  are  led  by  the  well-known 
alternation  between  the  glycosuric  and  the  articular  troubles 
to  regard  glycosuria  as  one  of  the  manifestations  of  gout, 
as  '  gout  in  the  liver '  in  opposition  to  '  gout  in  the  joints.' 
The  study  of  gouty  diabetes  is  thus  shown  to  be  another 
approach  to  the  study  of  the  pathology  of  gout.  Whilst 
it  affords  arguments  in  favour  of  the  neural  hypothesis,  it 
distinctly  favours  the  theory  that  the  liver  is  largely  con- 
cerned in  the  production  of  gout,  and  chiefly  by  virtue  of 
the  leading  part  which  it  takes  in  the  processes  of  meta- 
bolism and  of  nutrition. 


GOUT  AND  HEMORRHAGIC  DISEASES  167 


THE  RELATION  BETWEEN  GOUT  AND 
HEMORRHAGIC  DISEASES. 

For  a  valuable  study  of  these  diseases  Sir  Dyce  Duck- 
worth's work  should  be  consulted.  Splenic  hucocythcemia, 
in  which  the  very  large  amount  of  uric  acid  excreted  may 
give  rise  to  renal  calculus,  does  not  lead  to  gout,  and 
the  two  isolated  cases  reported*  must  be  regarded  as 
exceptional.  An  isolated  instance  of  purpura  and  one  of 
paroxysmal  hcBinatinuria  in  gouty  subjects  are  also  recorded. 

The  chief  interest  attaches  to  haemophilia.  Its  alleged 
gouty  connection,  contended  for  by  Rieken  as  early  as  1829, 
has  been  subsequently  supported  and  opposed  with  equal 
vigour.  Dr.  Wickham  Legg,  in  his  valuable  contribution 
to  this  subject,  '  A  Treatise  on  Haemophilia  '  (1872),  ques- 
tions the  correctness  of  Rieken's  original  propositions, 
which  are  as  follows  : 

'  I.  The  tendency  to  extreme  haemorrhages  has  been  of 
late  observed  only  in  those  whose  parents  or  grand- 
parents have  suffered  from  gout.  2.  In  those  members  of 
"bleeder"  families  who  have  escaped  the  tendency  to 
haemorrhage,  gouty  paroxysms  may  be  observed.  3.  In 
"  bleeders  "  themselves  gouty  paroxysms  are  nearly  always 
seen,  and  sometimes  an  alternation  of  the  joint  affection 
with  the  bleeding.  4.  Gout  is  a  disease  which  stands  in  a 
very  close  relation  to  the  blood  and  bloodvessels,  and 
often  appears  to  be  a  direct  cause  of  haemorrhage.' 

Sir  Dyce  Duckworth,  whilst  not  adopting  Rieken's 
extreme  view  that  haemophilia  is  an  anomalous  variety  of 
gout,  and  the  articular  attacks  practically  gouty  arthritis, 
adduces,    nevertheless,    strong   evidence    in    favour   of  a 

*  Cf.  Duckworth,  loc.  cii.,  p.  198. 


i68  GOUT  AND  HEMORRHAGIC  DISEASES 

definite  hereditary  relationship  between  gout  and  haemo- 
philia, and  of  an  association  between  them  in  respect  of 
structural  peculiarities.  Jonathan  Hutchinson  holds  that 
the  vascular  weakness  is  developed  by  gout  and  further 
specialized  by  serial  hereditary  transmission. 

Sir  Dyce  Duckworth  insists  upon  the  striking  parallelism 
shown  by  the  two  affections  in  the  direction  of  the  nervous 
system  (including  the  occasional  complication  of  epilepsy) ; 
in  the  direction  of  the  joints  ;  and  in  other  directions  also. 
He  also  notes  the  tendency  to  recurrence,  which  would 
support  the  view  that  the  haemorrhage  of  severe  haemo- 
philia was  that  of  a  '  gradual  accumulative  plethora  which 
must  perforce  discharge  itself.'  In  this  respect  also  an 
analogy  would  be  traceable  between  the  gouty  and  the 
haemophilic  groups. 


CHAPTER  XX. 
PLUMBISM  AND  LEAD-GOUT. 

THEIR  INCIDENCE  AND  GENERAL  MTIOLOGY. 

In  1854  Sir  A.  Garrod*  published  the  fact  that  '  at  least 
one  in  four  of  his  hospital  patients  suffering  from  gout 
had,  at  some  period  of  their  lives,  been  infected  by  lead, 
and  for  the  most  part  had  followed  the  occupation  of 
plumbers  or  painters.'  In  the  third  edition  of  his  work 
on  gout"f*  he  refers  to  prior  observations  of  this  association 
by  Musgrave,  Huxham,  William  Falconer  (1772),  C.  H. 
Parryl  (1807),  and  Todd,  and  to  the  descriptive  ex- 
pressions '  lead  arthralgia  '  or  '  metallic  rheumatism ' 
used  by  Sauvages. 

The  frequency  of  the  combination  of  lead  intoxication 
and  of  gout  among  lead-workers  in  London  has  been  con- 
firmed by  other  observers,  but  the  same  frequency  has 
not  been  noted  in  any  other  locality.  Christison's  original 
report  bore  witness  to  the  total  absence  of  lead-gout  in 
Edinburgh,  and  at  the  same  time  to  the  infrequency  of 
plumbism.  This  statement  has  subsequently  received 
some  qualification,  but  the  fact  remains  that  lead-gout  is 
exceedingly  uncommon,  not  only  in  Edinburgh,  in  the 
whole  of  Scotland,  and  in  some  of  the  Northern  towns  in 

*  'Med.  Chir.  Trans.,'  vol.  xxxvi.  f  Loc.  cit.,  p.  237. 

+  It  is  significant  that  Parry  attributed  the  effect  of  the  metal  to  its 
power  of  '  producing  arterial  plethora.' 


I70  PLUMBISM  AND  LEAD-GOUT 

England,  but  in  Ireland,  in  France,  and  on  the  Continent 
generally.  This  striking  contrast,  though  it  may  seem  at 
first  sight  likely  only  to  complicate  the  problem  of  gout, 
really  affords  help  towards  its  solution,  provided  we  can 
define  with  sufiicient  accuracy  the  main  differences  be- 
tween the  London  lead-workers  and  lead-workers  through- 
out the  world. 

Had  the  occurrence  of  lead-gout  been  absolutely  con- 
fined to  London  and  other  large  towns  in  the  South  of 
England,  and  strictly  excluded  from  the  North  and  from 
Scotland,  whilst  all  other  factors  were  identical,  important 
conclusions  might  have  been  framed.  It  would  have 
been  equally  obvious  that  gout  is  not  produced  by  lead 
per  se,  and  that  the  operation  of  certain  gout-producing 
causes,  absent  elsewhere,  but  present  in  England  and 
London,  is  vastly  assisted  by  it. 

The  statements  originally  made  by  Sir  A.  Garrod  can 
still,  in  spite  of  any  exceptions  which  have  since  been 
pointed  out,  be  accepted  as  substantially  correct,  and  as 
affording  a  fair  basis  for  inferences  ;  and  if  we  may  assume 
that  the  hours  of  labour,  the  degree  of  exposure,  and  the 
lesions  due  to  lead,  are  fairly  constant  qualities,  the  re- 
maining possible  differences  would  relate  mainly  to  race, 
climate,  and  diet. 

All  the  varieties  of  the  London  climate  are  to  be  found 
in  some  one  or  other  of  the  localities  belonging  to  the 
opposite  section.  The  towns  of  Scotland,  Newcastle,  and 
other  towns  in  the  North  of  England,  the  cities  of  wine- 
drinking  France  and  of  beer-drinking  Germany,  supply 
us  with  a  complete  scale  of  temperature  and  of  atmo- 
sphere. Again,  the  variety  of  races  contained  in  London 
minimizes  any  inference  based  upon  mere  nationality.  It 
is  clear  that  the  liability  of  the  Londoner  is  due  neither 
to  race  nor  to  climate.     Neither  is  it  the  direct  result  of 


PLUMBISM  AND  LEAD-GOUT  171 

life  in  a  large  town,  since  there  are  large  and  foggy  towns 
in  which  gout  does  not  prevail. 

A  leading  share  thus  clearly  falls  to  the  well-known 
peculiarities  of  the  London  workman's  dietary.  It  was 
Sir  A.  Garrod's  original  opinion  that  the  more  liberal 
diet  and  the  addiction  to  beer  of  a  special  kind  are  the 
most  likely  agents  in  the  lead-gout  of  London,  and  the 
same  view  still  commends  itself  to  us. 

The  case  of  the  German  workman,  likewise  a  liberal 
partaker  of  malt  liquor,  enables  us  still  more  closely  to 
identify  the  precise  source  of  the  trouble.  The  beer  of 
Germany  is  well  known  to  be  widely  different  from 
English  beer.  Stout  is  not  only  of  higher  alcoholic  per- 
centage, but  is  the  result  of  a  different  mode  of  fermenta- 
tion, and,  especially,  contains  a  much  larger  amount  of 
nutritive  material.  Within  the  British  Isles  the  main 
difference  as  regards  beverage  between  the  London  lead- 
workers  and  those  of  Ireland  and  of  the  North  is  that 
with  the  latter  the  consumption  of  beer  is  not  prevalent, 
spirits  being  the  favourite  drink. 

The  Share  of  Alcohol  in  the  Etiology  of  Lead-Gout. — 
Diet  and  beverage  being  jointly  answerable  for  the  lead- 
gout  of  London  artisans,  which  of  the  two  agencies  is  the 
most  active  ?  Here,  again,  conclusions  may  be  derived 
from  the  contrast  observed  in  plumbism. 

Granted  that  the  subjects  of  lead-intoxication  are  pre- 
disposed to  gout,  their  indulging  freely,  or  even  to  excess, 
in  spirits  certainly  does  not  lead  to  the  affection.  This 
is  amply  proved  by  the  observations  of  Christison  and  of 
others.  In  France,  even  the  heavy  wines  from  the  South, 
largely  consumed  by  every  class  of  workmen,  fail  to  cause 
gout  among  lead-workers.  Lastly,  in  Germany  lead-gout 
is  not  induced  by  the  lighter  beer  so  largely  consumed. 

If,  then,  as  may  fairly  be  concluded,   the  amount  of 


172  PLUMBISM  AND  LEAD-GOUT 

alcohol  contained  in  the  London  workman's  daily  stout 
would  not  of  itself  produce  gout,  the  harm  must  arise 
in  connection  with  the  non-alcoholic  constituents — the 
solids,  including  the  salts,  but,  above  all,  the  dietetic 
nutritive  solids,  viz.,  sugar  and  partly  fermented  malt. 

Here  again  the  question  arises  whether  in  themselves 
these  disguised  alimentary  supplies  would  have  any  effect 
whatever  if  taken  in  some  other  form  in  addition  to  the 
diet ;  or  whether  any  special  action  must  be  attributed  to 
the  way  in  which  their  ingestion  is  associated  with  that  of 
so  much  alcohol.  An  inquiry  into  the  clinical  history  of 
lead-workers  who  happen  to  be  teetotalers  would  be  indi- 
cated in  connection  with  this  point.  These  matters,  as 
well  as  the  dietetic  question  as  a  whole,  will  be  discussed 
more  fully  under  the  heading  of  diet. 

Thus  far,  then,  we  have  brought  the  problem  to  a 
partial  solution  :  the  gout  of  lead-workers  is  probably 
dependent  upon  some  peculiarity  of  intimate  nutrition, 
which  can  be  traced  outwardly  to  an  obvious  difference  in 
alimentation. 

THE  'LEAD  KIDNEY;  AND  ITS  ETIOLOGICAL 
RELATION  TO  GOUT. 

The  Excretion  of  Uric  Acid  in  Pluinbism.  —  Various 
observers  have  traced  a  close  analogy  between  the  renal 
lesions  of  gout  and  those  of  plumbism.  Garrod  has, 
moreover,  insisted  on  the  diminished  excretion  of  uric 
acid  in  lead-intoxication,*  and  based  on  these  two  obser- 
vations a  provisional  explanation  of  lead-gout. 

*  On  the  other  hand,  Gubler  and  Robin  (quoted  by  Rendu,  loc.  czf., 
p.  187)  find  the  urine  of  lead  patients  more  closely  analogous  to  that 
of  hepatic  cirrhosis — '  scanty,  and  charged  with  pigments  and  urates ' 
— and  analogous  also  to  those  specimens  among  the  gouty  urines 
analyzed  by  Bouchard  and  Lecorchd,  in  which  both  urea  and  uric  acid 
were  increased. 


THE  'LEAD  KIDNEY'  173 

Uric  acid  is,  according  to  Garrod,  very  difficult  to 
discover  in  the  blood  save  in  cases  of  gout,  but  is  almost 
invariably  present  in  cases  of  lead-poisoning,  indepen- 
dently of  gout. 

The  excretion  of  uric  acid  was  found  by  Garrod 
markedly  diminished  after  the  administration  of  the 
metal.  Moreover,  '  a  very  peculiar  phenomenon  was 
observed,  namely,  that  after  the  drug  had  been  given  for 
a  day  or  so,  a  sudden  arrest  of  the  excretion  of  uric  acid 
ensued,  and  the  function  of  the  kidneys  then  became 
more  or  less  intermittent ;  and  this,  it  will  be  remembered, 
was  also  found  to  be  the  case  in  patients  suffering  from 
chronic  gout.' 

'  It  would  appear,  therefore,  that  in  individuals  impreg- 
nated with  lead  the  blood  becomes  loaded  with  uric  acid, 
not  from  its  increased  formation,  but  from  its  imperfect 
excretion  ;  and  this  is  of  much  interest  in  connection  with 
the  fact  that  the  subjects  of  lead-poisoning  are,  cczteris 
paribus,  more  liable  to  be  affected  with  gout,  and,  as  we 
shall  find  further  on,  that  those  who  inherit  the  gout)'- 
diathesis  are  more  likely  to  become  poisoned  by  the 
imbibition  of  lead.' 

'  Before  concluding  this  subject,  I  may  mention  that  I 
have  seen  several  cases  in  which  the  medical  administra- 
tion of  lead  salts  has  caused  severe  attacks  of  gout  in 
patients  who  had  previously  suffered  from  the  disease ; 
and  the  attacks  have  recurred  so  frequently  whenever  the 
medicine  has  been  renewed,  that  there  could  be  no  doubt 
that  the  phenomena  stood  in  the  relation  of  cause  and 
effect  to  each  other.'* 

The  Renal  Changes  due  to  Lead. — The  damaging  effect 
of  lead  on  the  kidney  has  been  studied  by  Charcot  and 

*  Garrod,  loc.  cit.,  p.  243. 


174  CONCLUSIONS 


Gombault*  in  guinea-pigs  fed  with  white  lead.  The 
kidney  was  not  affected  in  the  acute  cases ;  but  in  chronic 
intoxication  it  first  suffered  intratubal  epithehal  changes, 
which  were  followed  by  interstitial  disease  in  patches,  and 
ultimately  by  granular  atrophy. 

The  same  results  have  been  obtained  by  Prevost  and 
Binet,  and  by  Ellenberger  and  Hofmeister  (quoted  by 
Levison,  loc.  cit.,  p.  58). 

CONCLUSIONS 

In  spite  of  this  similarity,  both  structural  and  func- 
tional, between  gout  and  plumbism,  it  may  be  contended 
that  the  proclivity  to  gout  set  up  by  chronic  lead-intoxi- 
cation is  not  mainly,  if  at  all,  due  to  the  state  of  the 
kidney.  Before  admitting  that  it  was  so,  we  should 
require  evidence  that  the  renal  lesion  induced  by  lead  in 
London  workmen,  and  their  resulting  renal  disability, 
were  more  marked  than  in  any  other  subjects.  Were  the 
lesion  to  be  regarded  as  a  constant  factor,  not  varying 
with  locality,  we  should  expect  at  least  a  proportion  of 
gouty  cases  among  lead-workers  in  every  other  part  of 
the  world.  The  practical  immunity  reported  from  most 
quarters  is  a  serious  difficulty  in  our  accepting  the  renal 
inadequacy  theory  of  Garrod. 

If  renal  inadequacy  were  mainly  responsible  for  the 
result,  we  should  expect  a  larger  incidence  of  gout  in  other 
types  of  kidney  disease  among  those  equally  addicted  to 
stout  and  high  living.  It  is  not  in  plumbism  alone  that 
kidney  changes  involving  diminished  function  prevail 
without  any  gout  being  produced,  A  very  large  propor- 
tion, if  not  the  majority,  of  the  cases  of  chronic  renal 
disease  run  through  their  stages  without  any  gout  being 
developed.  This  objection  would  be  yet  stronger,  were  it 
*  'Archives  de  Physiologic  Normale  et  Pathologique,'  1881. 


CONCLUSIONS  175 


not  possible  to  argue  that  the  severity  of  the  renal  disease 
may  be  in  itself,  owing  to  the  cachexia  and  debility  which 
it  sets  up,  a  protection  against  any  gout — a  point  to  be 
kept  in  mind  in  aetiological  discussions. 

The  matter  is  not,  however,  quite  so  simple.  It  is 
admitted  that  the  liability  to  lead  intoxication  is  not 
everywhere  the  same  in  proportion  to  the  exposure.*  It 
was  long  since  pointed  out  by  Garrod  that  plumbism 
develops  earlier  and  in  a  more  severe  form  in  the  gouty 
than  in  other  subjects,  and  it  is  possible,  as  suggested  by 
Duckworth,  that  in  London,  although  new-comers  are  by 
no  means  exempt,  the  tendency  to  gout  may  be  inherited 
by  many  of  those  who  develop  lead-gout.  Thus,  the 
theory  of  renal  inadequacy  does  not  receive  much  sup- 
port from  a  study  of  cases  of  lead-gout ;  and  the  share 
attributable  to  renal  defects  would  dwindle  almost  to 
vanishing  if  it  were  to  appear  that  the  combination  most 
favourable  to  the  development  of  gout,  as  well  as  of  lead- 
gout,  was  a  minimum  of  kidney  disease  with  a  maximum 
of  digestive  efficiency. 

Our  inferences  thus  far  enable  us  to  add  another 
important  general  proposition  to  that  previously  derived 
from  a  study  of  leucocythsemia,  and  of  other  diseases 
accompanied  with  uricacidcemia.  It  was  shown  that  gout 
does  not  consist  merely  in  an  excess  of  uric  acid.  It  is  now 
clear  that  gout  is  not  produced  by  lead  per  se,  and  that  gout 
is  not  due  to  alcohol  per  se. 

As  regards  the  aetiology  of  lead-gout,  our  conclusions 
of  a  negative  kind  may  be  summed  up  as  follows  : 

*  Christison's  original  report  as  to  the  absolute  infrequency  in 
Edinburgh  of  lead-intoxication,  as  well  as  of  gout,  has  not  been 
endorsed  by  all  observers  ;  and  from  various  other  quarters  we  have 
evidence  of  the  frequency  of  various  saturnine  symptoms,  with  an 
almost  complete  absence  of  lead-gout. 


176  CONCLUSIONS 


1.  Lead-gout  is  not  due  to  the  destructive  renal  changes 
alone  which  are  determined  by  lead. 

2.  Gout  itself  not  being  observed  in  the  majority  of 
cases  of  the  various  forms  of  nephritis,  the  derivation  of 
saturnine  gout  from  lead  nephritis  is  not  proved. 

3.  Lead-gout  is  not  brought  about  by  wine  in  France, 
nor  by  beer  in  Germany,  nor  by  spirits  in  spirit-consum- 
ing districts  in  this  country. 

4.  Lead-gout,  as  seen  in  London  and  in  some  other 
English  towns,  is  most  probably  connected  with  the  use 
of  stout  or  porter ;  and  it  follows  from  the  second  pro- 
position that  it  is  not  the  amount  of  alcohol  contained 
in  that  beverage  which  is  answerable  for  the  causation, 
though  alcohol  taken  in  that  form  may  contribute  some 
share.  Most  probably  the  nutritive  elements  in  beer, 
and  especially  the  mode  in  which  they  are  supplied  at 
recurring  intervals,  together  with  the  special  conditions 
of  fermentation  and  of  alcoholization,  are  the  essential 
determining  factors. 

FURTHER     SUGGESTIONS     ARISING     IN     CONNECTION 

WITH   THE  CHEMICAL  AND  PHYSIOLOGICAL 

ACTION  OF  LEAD. 

Passing  now  to  the  question  of  the  positive  or  direct 
agencies,  we  must  repeat  that,  although  in  London  and 
in  other  districts  in  England  all  classes  of  artisans  are 
addicted  to  stout,  lead-workers  are  afflicted  with  gout  in 
a  much  higher  proportion  than  any  other  set,  and  it 
seems  impossible  not  to  connect  this  fact  with  the 
influence  of  lead.  We  must  regard  lead  as  favouring  the 
development  of  gout  in  an  appreciable  degree.  In  what 
does  the  influence  consist  ? 

The  same  dietetic  and  hygienic  influences  which 
generate    gout  might   also   favour  saturnine   intoxication. 


FURTHER  SUGGESTIONS  177 

There  is,  perhaps,  some  importance  in  the  observation 
that  the  acetic  fermentation  of  heavy  beer  may  aid  in 
sharpening  the  attacks  of  gout,  whilst  it  may  promote 
the  introduction  into  the  system,  and  the  rapid  circula- 
tion, of  lead  in  a  soluble  form,  or  its  reabsorption  after 
previous  deposition,  both  as  an  acetate  and  as  a  bicar- 
bonate. The  insolubility  of  urate  of  lead  would  likewise 
tell  in  two  directions,  favouring  the  retention  both  of  the 
lead  and  of  the  uric  acid. 

Sir  W.  Roberts  and  Dr.  Haig  regard  lead  as  favouring 
precipitation  of  uric  acid  in  the  tissues.  Again,  lead, 
by  diminishing  the  alkalinity  of  the  blood,  as  shown  by 
Dr.  Ralfe,  would  in  a  corresponding  degree  lessen  the 
solubility  of  uric  acid.  When,  therefore,  every  reserva- 
tion has  been  made  in  favour  of  a  possible  antecedent 
gouty  agency  as  predisposing  to  lead-intoxication,  we 
may  still  regard  the  opposite  relation  as  being  in  London 
the  most  common  one,  and  we  may  provisionally  draw 
from  it  certain  inferences  capable  of  throwing  light  on 
gout  itself. 

Assuming  that  we  are  right  in  refusing  to  recognise 
the  renal  lesions  of  plumbism  as  the  chief  cause  at  work, 
wherein  would  the  influence  reside  ?  Attention  has  per- 
haps been  too  exclusively  concentrated  on  the  kidney. 
This  is  not  the  only  organ  to  suffer.  As  a  fact,  lead 
exercises  its  evil  influence  upon  various  other  structures, 
which  may  be  enumerated  irrespective  of  any  attempt  at 
defining  their  relative  value :  (i)  The  blood ;  (2)  the 
circulation ;  (3)  the  nervous  system  ;  (4)  the  liver ;  (5) 
the  alimentary  canal.  Are  we  sure  that  any  of  these 
forms  of  trouble  may  not  have  a  share  in  setting  up  the 
liability  ? 

In  the  blood,  under  the  broad  heading  of  anaemia, 
changes   have  been  described   in  the  shape  and  in    the 

12 


378  FURTHER  SUGGESTIONS 

size  of  the  red  corpuscles.  Leucocytosis  has  also  been 
recognised  among  the  results  of  lead.  Lastly,  uric- 
acidgemia  has  been  described  by  some  and  denied  by 
others.  Even  these  coarse  features  are  imperfectly  known 
to  us,  but  of  the  functions  of  the  cellular  elements  of  the 
blood  our  knowledge  is  imperfect,  and  concerning  the 
pathological  alterations  in  these  functions  we  are  abso- 
lutely in  the  dark.  This  is  precisely  one  of  the  fields 
most  likely  to  be  exposed  to  the  subtle  influence  of  lead. 

The  high  arterial  tension  observed  in  plumbism  is  a  proof 
of  increased  peripheral  resistance.  The  mechanism  of  the 
latter  has  been  attributed  to  a  loss  of  due  proportion 
between  the  capillary  bore  and  the  diameter  of  the  blood 
corpuscles ;  be  this  as  it  may,  there  is  no  doubt  that  a 
tonic  constriction  of  the  peripheral  vessels  is  one  of  the 
results  of  lead-intoxication. 

Vastly  more  important  are  the  results  which  may  pos- 
sibly be  traced  to  the  effect  of  lead  on  the  nervous  system. 
Lead  is  a  recognised  cause  of  peripheral  neuritis.  That 
it  acts  on  the  nervous  centres  is  demonstrated  by  the 
tremor,  and  other  advanced  toxic  effects  ;  but  short  of 
these  there  is  room  for  slighter  changes  in  the  grey  matter 
and  in  the  nerves,  sufficient  to  modify  trophic  and  meta- 
bolic processes  over  wide  areas  of  innervation.  These 
possibilities  cannot  be  considered  as  remote  in  relation  to 
a  disease  in  which  nervous  agencies  are  prominent,  and 
in  connection  with  the  chemical  demonstration  of  the 
presence  of  lead  in  the  nervous  centres.  Nevertheless, 
they  are  for  the  present  purely  speculative. 

The  advocates  of  the  nervous  origin  of  gout  and  of 
lead-gout  would  find  here,  as  in  every  other  presentation 
of  gout,  ample  illustrations  for  their  contention.  Two 
facts  have  been  regarded  as  specially  suggestive  of  an 
influence   of  the   central   nervous   system  :    (i)  The    not 


FURTHER  SUGGESTIONS  179 

infrequent  combination  of  paralyzing  neuritis  with  arth- 
ritic or  oedematous  changes.  (2)  The  observation  that, 
in  some  non-gouty  districts,  marked  arthritic  changes 
occur,  to  which  were  appHed  the  names  '  saturnine  arthro- 
pathy '*  and  '  saturnine  arthralgia  '  (a  painful  affection  of 
the  legs  and  joints  occurring  with  the  onset  of  paralysis, 
without  swelling  of  the  joints).  On  these  points,  and  on 
the  whole  subject  of  lead-intoxication  in  gout,  Sir  Dyce 
Duckworth's  treatise  would  be  consulted  with  profit. 

We  are  able  to  refer  with  much  greater  assurance  to 
the  connection  with  lead  of  well-known  clinical  affections 
of  the  digestive  organs,  the  liver  and  intestine.  Lead  perhaps 
shows  a  greater  tendency  than  other  metals  to  be  distri- 
buted throughout  the  body  rather  than  collected  in  any 
one  organ.  This  gives  it  additional  facilities  for  being 
periodically  redissolved  in  certain  states  of  the  blood,  and 
circulated  to  the  detriment  of  the  system  at  large,  and 
in  particular  of  the  neuro-muscular  structures. 

The  most  common  and  the  most  familiar  of  all  symp- 
toms of  plumbism  is  its  astringent  effect  upon  the  mus- 
cular fibre  of  the  intestine ;  constipation  is  set  up, 
occasionally  leading  to  colic.  It  is  unnecessary  to  insist 
on  the  direct  influence  which  constipation  must  exercise 
upon  digestion  and  assimilation.  Its  indirect  influences 
are  probably  hardly  second  in  importance  ;  torpidity  and 
congestion  of  the  liver  are  necessary  results  of  intestinal 
torpor,  and,  for  all  who  admit  that  gout  is  essentially  a 
disease  of  faulty  nutrition,  this  represents  a  factor  of 
paramount  importance,  with  special  bearing  on  the  ques- 
tion of  treatment. 

*  "  Dropped  wrist"  is  apt  to  present  a  painless  tumour,  with  dis- 
placement backwards  of  the  bones  and  distension  of  the  synovial 
sheath. 


VI. 
THE  CLINICAL  STUDY  OF  GOUT. 


CHAPTER  XXI. 

THE  CLINICAL  TYPES  AND  STAGES  OF  GOUT. 

The  older  classification  of  gout  into  acute  and  chronic, 
sthenic  and  atonic,  arthritic  and  visceral,  or  regular  and 
irregular,  is  not  open  to  much  criticism.  For  working 
purposes  something  less  rigid  and  more  life-like  might  be 
welcome  and  of  use  :  a  classification  of  the  patients  in 
respect  of  their  variety  of  gout,  rather  than  of  the  gout 
apart  from  them.  This  indication  is  probably  greater  in 
connection  with  this  than  with  any  other  affection,  if  we 
regard  it  as  a  deviation  of  the  normal  functions,  rather 
than  as  a  morbid  entity  capable  of  being  considered  apart 
from  its  bearer.  Indeed,  its  clinical  and  pathological 
study  cannot  be  profitably  attempted  without  some  pre- 
liminary acquaintance  with  its  multiple  forms. 

Let  alone  the  great  variety  of  constitutions  upon  which 
gout  may  be  grafted* — a  complex  study  which  must  be 

*  Duckworth  {loc.  at.,  p.  455)  draws  attention  to  Laycock's  teaching, 
that  the  varieties  of  gout  depend  on  the  varieties  in  the  constitutions. 
All  diatheses  are  liable  to  gouty  affections,  but  each  of  them  modifies 
the  gouty  symptoms  and  evolution.  He  recognised  the  following 
varieties  :  (i)  The  sanguine  arthritic  or  'John  Bull'  type,  with  pre- 
valence  of  sthenic   and   regular  paroxysms  ;   (2)  less  common,  the 


THE  CLINICAL  TYPES 


deferred — there  are  broad  clinical  types  presenting  con- 
trasts of  the  first  order. 

To  the  elementary  distinction  between  acquired  and 
inherited  gout  we  need  not  refer,  beyond  repeating  that 
all  hereditary  gout,  if  traced  sufficiently  far  back,  is 
originally  acquired  gout. 

Groups  I.  and  II. — Two  well-defined  types  occur  at  the 
top  and  at  the  bottom  of  the  long  list  of  degrees  and 
varieties.  At  one  extremity  is  gout  limited  to  a  single  acute 
attack,  preceded  and  followed  by  a  condition  of  practically 
perfect  health ;  at  the  other  gouty  cachexia,  the  result  of 
many  years  of  constantly  recurring  gouty  troubles. 

Groups  III.  and  IV. — The  intermediate  types  need  not 
be  defined  in  full  detail.  The  mitigation  of  the  worst  type 
forms  the  class  of  inveterate  gout  with  moderate  cachexia; 
and  we  are  familiar  with  a  large  class  of  cases  related  to 
Group  I.  in  which  acute  attacks  rectirring  at  long  intervals  are 
separated  by  periods  of  sound  or  robust  health. 

Group  V. — A  very  large  and  heterogeneous  group  is 
made  up  of  all  those  cases,  too  varied  to  repay  further 
classification,  the  common  features  of  which  are :  (a)  the 
mildness  of  the  arthritic  troubles,  and  (b)  the  prominence 
of  the  constitutional  element  of  gout,  with  a  tendency  to 
visceral,  nervous,  and  cutaneous  complications.  This 
group  comprises  most  of  the  cases  of  inherited  gout  and  of 
gout  in  the  female.     It  corresponds  in  great  part  to  the 


bilious  arthritic  type,  apt  to  be  asthenic,  and  to  develop  earlier  ;  (3)  the 
'  nervous  arthritic '  type.  Two  forms  of  gouty  disposition  were  included 
in  this  category,  one  being  complicated  with  struma,  viz.,  the  '  neuro- 
arthritic  type  proper,'  with  tendency  to  affections  of  the  cerebro-spinal 
axis,  with  its  nerves  and  membranes  ;  the  other  with  the  sanguine  or 
the  bilious  type,  viz.,  the  '  neuro-vascular  or  vaso-motor '  type,  in  which 
the  circulation  of  the  nerve-centres  suffers  by  reason  of  altered  vaso- 
motor action  '  etc. 


1 82  THE  CLINICAL  TYPES 

group  sometimes  termed  irregular  gout.  Most  instances 
of  atonic  gout  also  belong  to  this  category.  Lastly,  it 
includes  also  the  attenuated  forms  for  which  the  term 
goutiness  has  been  proposed. 

Group  VI. -^Lead-gout  is  sufficiently  differentiated  by 
some  of  its  peculiarities  to  be  described  independently  of 
other  forms.  Some  of  its  characteristics  assimilate  it 
closely  to  Group  V. 

Sub-Varieties. — In  each  of  the  groups  special  peculiarities 
give  occasion  for  further  sub-division.  Thus  in  chalky  or 
tophaceous  gout,  the  local  deposits  of  biurate  or  tophi, 
which  may  occur  in  any  of  the  groups,  are  specially 
abundant.  This  feature  is  of  marked  frequency  in  the 
group  of  cachectic  cases. 

Another  important  clinical  sub-variety  is  that  in  which 
gout  develops  in  the  subjects  of  constitutional  lithiasis  or 
gravel.  Many  of  these  are  cases  of  inherited  gout,  and 
most  of  them  belong  to  Group  V. 

The  albuminuric  variety  is  not  restricted  to  any  of  the 
types,  but  it  is  most  common  in  inveterate  gout  and  in 
gouty  cachexia  ;  the  latter  is  largely  brought  about  by  the 
evil  influence  of  kidney  disease. 

Most  of  the  diabetic  and  glycosuria  cases  belong  to 
Group  v.,  but  the  affection  may  also  occur  in  the  other 
groups. 

Gouty  metastasis,  sometimes  termed  metastatic  gout, 
does  not  constitute  a  nosological  group  :  it  is  merely  an 
accident  of  which  each  of  the  groups  mentioned  might 
furnish  instances. 

Again,  visceral  gout  is  a  convenient  general  heading  for 
the  numerous  abarticular  manifestations  to  which  all 
gouty  subjects  are  liable,  but  the  chief  contingent  of  cases 
is  furnished  by  Group  V. 

Suppressed  or  retrocedent  gout  is  the  most   striking  and 


THE  PRE-ARTHRITIC  STAGE  183 

ominous  mode  of  visceral  gout,  and  much  clinical  and 
literary  attention  has  been  devoted  to  it. 

No  practical  object  would  be  served  by  extending  our 
list  of  sub-varieties,  but  a  systematic  clinical  study  will 
imply  separate  consideration  of  the  clinical  aspects  of  gout 
in  connection  with  the  chief  organs  and  functions.  The 
description  of  the  symptoms  of  gout  will  be  given  under 
corresponding  headings. 


THE  CLINICAL  ANTECEDENTS  OF  ACUTE  GOUT:  THE 
PRE-ARTHRITIC  STAGE. 

A  first  fit  of  the  gout,  coming  unawares  upon  a  man  of 
healthy  parentage  and  antecedents,  prompts  us  to  inquire, 
What  was  the  previous  state  shortly  before  the  fit  ?  Was 
he  perfectly  sound  previous  to  the  two  or  three  days  of 
premonitory  indisposition  ?  or  was  he  gouty  ?  The 
question  has  practical  as  well  as  pathological  importance. 

We  have  been  in  the  habit  of  looking  upon  the  fit  of 
gout  as  a  cHmax,  the  result  of  long  persistence  in  habits 
conducive  to  the  disease.  Do  the  facts  always  bear  out 
this  view  ?  The  chief  difficulty  occurs  in  the  cases  in- 
cluded under  the  clinical  Group  I.,  in  which  the  patient 
has  one  fit  and  never  another,  and  might  in  later  years 
almost  pass  for  a  non-gouty  subject,  but  for  his  own 
report  of  a  bad  attack  of  gout  in  the  toe  many  years 
previously. 

On  the  other  hand,  a  patient  who  has  never  consciously 
suffered  from  articular  troubles  is  not  infrequently  pro- 
nounced by  competent  observers  to  be  '  gouty.'  The 
recognition  of  a  pre-arthritic  constitutional  change  would 
enable  us  to  connect  with  gout  cases  of  this  sort  who, 
according  to  the  more  strict  definition  of  the  disease  as  an 
essentially  arthritic  affection,  could  not  be  included. 


1^4  THE  PRE-ARTHRITIC  STAGE 

Many  a  patient  who  has  never  had,  and  perhaps  never 
may  have,  articular  gout  presents  symptoms  usually  ob- 
served in  those  who  are  confirmed  gouty  arthritics ;  and  it 
is  during  this  pre-arthritic  stage,  whether  acquired  or 
hereditary,  that  the  various  manifestations  sometimes 
spoken  of  as  irregular  gout  are  apt  to  arise,  and  to  be 
rightly  or  wrongly  ascribed  to  the  gouty  influence. 

Sydenham  describes  the  onset  of  the  fit  as  sudden.  Yet 
the  fact  that  in  a  few  cases  a  slow  preliminary  implication 
of  the  joints  may  precede  the  acute  attack  for  some  length 
of  time  suggests  a  provisional  distinction  between  (i)  a 
'  pre-arthritic  '  stage  in  the  full  sense  of  the  term,  and 
(2)  a  silent  or  '  quiet  arthritic '  stage — the  gouty  attack 
being  sometimes  preceded  by  the  first  only,  in  other  sub- 
jects by  the  second  also. 

Latent  Arthritic  Gout. — Autopsies  being  unusual  in  this 
disease,  it  is  difficult  to  form  a  correct  estimate  of  the 
proportion  of  cases  in  which  the  arthritic  form  may  have 
been  latent  in  those  who  had  presented  for  clinical  observa- 
tion only  the  so-called  irregular  symptoms  of  gout. 

Uratic  incrustations  have  sometimes  been  reported  in 
the  joints  of  those  who,  so  far  as  could  be  ascertained, 
had  never  suffered  from  any  arthritic  symptoms.  These 
are  instances  of  an  absolutely  latent  deposition  of  uric  acid. 
In  the  absence  of  a  post-mortem  examination,  if  put  down 
to  gout  at  all,  they  might  have  been  clinically  reckoned 
as  pure  instances  of  pre-arthritic  gout,  and  classified  as 
entirely  free  from  all  joint  implication.  This  possible 
fallacy  must  be  carefully  borne  in  mind  in  every  discussion 
of  the  dictum,  '  Without  uric  acid  in  the  joints,  no  gout.' 

Quiet  Arthritic  Gout. — Cases  of  quiet  gout  form  a  distinct 
and  large  group.  Here  the  joints  are  obviously  impli- 
cated ;  digital  nodules,  or  even  small  tophi,  are  present,  and 
there  is  some  impairment  in  movement.      The  arthritic 


THE  PRE-ARTHRITIC  STAGE  185 

changes,  however,  are  altogether  chronic,  and  almost 
painless,  and  in  that  state  they  may  continue  for  consider- 
able periods  of  time.  Indeed,  here  again  an  acute  arth- 
ritic attack  may  never  make  its  appearance.  This  form 
is  specially  common  among  women,  and  is  capable  of 
being  mistaken  for  osteo-arthritis.  Again,  tophaceous 
gout  may  proceed  to  considerable  developments  before  it 
is  complicated  with  any  genuine  acute  attack,  although 
the  formation  of  tophi  is  very  apt  to  follow  the  acute 
seizures.  Tophi  in  the  auricle  are  of  every-day  occurrence 
where  no  definite  warnings  of  gout  have  been  experienced. 

Greater  uniformity  would  be  established  between  the 
various  clinical  types  were  it  obvious  that  the  gouty 
seizure  is  never  a  primary  event,  and  that  in  all  cases  a 
pre-arthritic  gouty  stage  occurs.  In  many  cases  gout 
undoubtedly  precedes  the  acute  joint  troubles,  and  in 
some  these  never  come  about,  in  spite  of  a  long  con- 
tinuance of  goutiness. 

Diametrically  opposed  to  these  instances  of  gout, 
whether  hereditary  or  acquired,  in  which  the  constitutional 
change  is  manifest,  but  the  articular  implications  are 
almost  indefinitely  delayed,  or  apt  to  be  of  the  asthenic 
and  chronic  type,  is  the  large  class  of  acquired,  sthenic 
gout  in  which  the  pre-arthritic  stage  is  latent  or  of  vanish- 
ing duration.  In  them,  if  present  at  all,  this  period  is 
one  of  silent  and  slowly  progressive  general  nutritive 
changes,  the  treatment  of  which  is  usually  neglected. 
The  nature  of  these  pre-arthritic  changes  is  matter  of  pure 
speculation  ;  we  only  know  that  they  result  in  a  structural 
delicacy  akin  to  degeneration,  which  is  transmissible  by 
inheritance,  and  the  long  continuance  of  which  in  the 
individual  tends  towards  the  so-called  gouty  cachexia. 
This  final  stage,  however,  is  never  reached  except  through 
a  long   period   of  joint-trouble ;    and   opinions    are   still 


THE  PME-ARTHRITIC  STAGE 


divided  as  to  whether  the  constitutional  or  the  local 
trouble  should  be  blamed  for  the  mischief. 

How  long  the  pre-arthritic  or  evolutionary  stage  may 
continue,  or  whether,  once  originated,  it  may  ever  be 
arrested,  we  have  hitherto  no  means  of  judging.  In 
shght  cases,  under  the  influence  of  appropriate  treatment 
or  diet,  it  is  conceivable  that  the  advent  of  the  arthritic 
period  might  be  indefinitely  delayed.  Under  this  in- 
hibitory treatment  the  patient's  condition  would  be 
analogous  to  that  of  persons  inheriting  a  strong  tendency 
to  gout,  but  who  may,  nevertheless,  permanently  escape 
any  arthritic  implication. 

In  conclusion,  the  duration  of  the  pre-arthritic  stage 
must  remain  an  open  question,  so  long  as  we  are  in 
ignorance  as  to  the  nature  of  the  changes  themselves,  and 
as  to  the  elements  of  variability  special  to  individual 
temperaments  and  circumstances.  The  more  stormy 
attacks  in  the  robust  often  seem  to  have  been  preceded 
by  the  least  premonitions.  These  are  also  the  cases 
which  sometimes  seem  to  throw  off  the  gout  for  long 
periods,  as  though  the  impression  made  on  the  nutrition  of 
the  tissues  had  been  a  transient  one  only,  and  any  changes 
in  the  latter  purely  superficial.  In  others,  however,  the 
acute  attacks  pass  away,  but  the  constitutional  state 
remains. 

There  would  appear  to  be  more  real  danger  to  health 
in  the  evolutionary  stage  than  in  the  acute  attack.  In- 
deed, the  acute  attack  has  long  been  regarded  in  a  sense 
as  curative  and  as  a  clearance  for  the  system.  According 
to  Sir  A.  Garrod,  the  deposit  may  be  partly  destroyed  by 
the  attack,  and  Sydenham  held  that  the  materia  peccans 
might  be  got  rid  of  by  insensible  perspiration  or  other- 
wise. 


CHAPTER  XXII. 

THE  ACUTE  ARTHRITIC  ATTACK. 

Sydenham's  description  of  the  acute  attack  has  never 
been  surpassed,  and  will  never  cease  to  be  quoted."^  It 
will  be  found  to  agree  with  those  given  by  the  most  recent 

*  'Towards  the  end  of  January  or  the  beginning  of  February, 
suddenly  and  with  scarcely  any  premonitory  feelings,  the  disease 
breaks  out.  Its  only  forerunner  is  indigestion  and  crudity  of  the 
stomach,  which  troubles  the  patient  for  some  weeks  previous  to  the 
attack.  His  body  also  feels  swollen,  heavy,  and  windy,  symptoms 
which  increase  from  day  to  day  until  the  fit  breaks  out.  A  few  days 
before  this,  torpor  comes  on,  and  a  feeling  of  flatus  along  the  legs  and 
thighs.  Besides  this,  there  is  a  spasmodic  affection,  whilst  the  day 
before  the  fit  the  appetite  is  unnaturally  hearty.  The  victim  goes  to 
bed  in  good  health  and  sleeps.  About  two  o'clock  in  the  morning  he 
is  awakened  by  severe  pain,  generally  in  the  great  toe  ;  more  rarely  in 
the  heel,  ankle,  or  instep.  This  pain  is  like  that  of  a  dislocation  of  the 
bones  of  these  parts,  and  is  accompanied  by  a  sensation  as  of  chilly 
water  poured  over  the  veins  of  the  suffering  joint.  Then  follow  chills 
and  shivers,  and  a  little  fever.  The  pain,  which  was  at  first  moderate, 
becomes  gradually  more  intense,  and  while  it  increases,  the  chills  and 
shivers  die  out.  Every  hour  that  passes  finds  it  greater,  until  at 
length  at  night-time  it  reaches  its  worst  intensity,  and  insinuates  itself 
with  most  exquisite  cruelty  among  the  numerous  small  bones  of  the 
tarsus  and  metatarsus,  in  the  ligaments  of  which  it  is  lurking.  Now 
it  is  a  violent  stretching  and  tearing  of  the  ligaments,  now  it  is  a 
gnawing  pain,  and  now  a  pressure  and  tightening.  So  exquisite  and 
lively  meanwhile  is  the  feeling  of  the  part  affected,  that  it  cannot  bear 
the  weight  of  the  bedclothes  nor  the  jar  of  a  person  walking  in  the 
room.  Hence  the  day  is  passed  in  torture,  and  a  restless  rolling,  first 
to  one  side  then  to  the  other,  of  the  suffering  limb,  with  perpetual 
change  in  posture  ;  the  tossing  of  the  body  being  about  as  incessant 
as  the  pain  of  the  tortured  joint,  and  being  at  its  worst  as  the  fit  is 


1 88  THE  ACUTE  ARTHRITIC  ATTACK 

authorities,  and  in  particular  by  Sir  A.  Garrod,  according 
to  whom  the  events  are  about  as  follows : 

Good  health — sometimes  unusually  good  health — may 
immediately  precede  the  acute  sthenic  attack.  At  i.o  to 
4.0  a.m.  the  patient  wakes,  frequently  with  slight  shiver- 
ing, and  with  more  or  less  pain  in  the  ball  of  the  toe. 
Feverishness  follows,  whilst  the  pain  increases.  It  is 
described  as  '  burning,  throbbing,  with  tension  and  stiff- 
ness.' After  some  hours  partial  relief  is  obtained  and 
ushered  in  by  gentle  perspiration.  On  waking  in  the 
morning,  the  patient  finds  the  toe  swollen,  the  skin  tense 
and  shiny  and  exquisitely  tender,  with  distended  veins. 

coming  on.  Hence  the  vain  efforts  by  change  of  posture,  both  in  the 
body  and  the  Hmb  affected,  to  obtain  an  abatement  of  the  pain.  This 
goes  on  towards  the  second  or  third  hour  of  the  morning  (a  whole 
day  and  night  after  the  first  outbreak  of  the  fit),  such  time  being 
necessary  for  the  moderate  digestion  and  dispersion  of  the  peccant 
matter.  The  patient  then  has  a  sudden  respite,  which  he  falsely 
attributes  to  the  last  change  of  position.  A  gentle  perspiration  is 
succeeded  by  sleep. 

'  He  wakes  freer  from  pain,  and  finds  the  part  recently  affected 
swollen.  Up  to  this  time  the  only  visible  swelling  had  been  that  of 
the  veins  of  the  affected  joint.  Next  day  (perhaps  for  the  next  two  or 
three  days),  if  the  generation  of  the  gouty  matter  have  been  abundant, 
the  part  affected  is  painful,  getting  worse  towards  evening,  and  better 
towards  morning.  A  few  days  after,  the  other  foot  swells,  and  suffers 
the  same  pain.  The  pain  in  the  latter  regulates  the  state  of  the  one 
first  attacked,  for  the  more  acutely  it  is  tortured,  the  more  perfect  is 
the  abatement  of  suffering  and  the  return  of  strength  in  the  other. 
Nevertheless,  there  is  a  repetition  in  the  second  case  of  all  the  misery 
of  the  first,  both  as  regards  intensity  and  duration.  Sometimes 
during  the  first  days  of  the  disease  the  peccant  matter  is  so  exuberant 
that  one  foot  is  insufficient  for  its  discharge.  It  then  attacks  both,  and 
that  with  equal  violence.  Generally,  however,  it  takes  the  feet  in 
succession '  ('  A  Treatise  on  Gout  and  Dropsy.')  (The  works  of 
Thomas  Sydenham,  M.D.,  translated  from  the  Latin  edition  of  Dr. 
Greenhill,  with  a  life  of  the  author,  by  R.  G.  Latham,  M.D.,  etc.,  in 
two  volumes.  London  :  printed  for  the  Sydenham  Society,  MDCCCL. 
Vol.  ii.,  p.  121  et  seq.). 


THE  ACUTE  ARTHRFTIC  ATTACK  189 

In  the  worst  cases  the  pain  is  intolerable,  the  slightest 
vibration  or  the  slightest  weight  calling  forth  fresh  agony. 
During  the  day  it  may  still  be  severe,  but  its  return  is 
generally  delayed  until  the  second  night.  This  alterna- 
tion may  proceed  for  days,  or  in  a  modified  form  for 
weeks. 

First  attacks,  and  often  subsequent  attacks,  usually 
implicate  the  ball  of  one  great  toe  only,  sometimes  chang- 
ing over  to  the  other  great  toe  or  sometimes  travelling  to 
the  inner  side  of  the  foot. 

'  When  the  attack,  or,  more  properly  speaking,  the 
series  of  attacks,  is  about  to  terminate,'  the  local  tension, 
swelling,  redness  and  vascular  fulness  lessen,  the  skin 
pits  on  pressure,  and  itching  of  the  skin,  with  desquama- 
tion, soon  follows. 

In  the  minor  attacks,  to  which  Garrod  refers  as  the 
'  acute  asthenic  gout,'  feverishness  may  be  absent,  there 
is  less  swelling,  heat,  and  redness  ;  but  oedema,  with  sub- 
sequent itching  and  peeling,  are  observed.  Garrod 
observes  that  this  lesser  form  is  more  apt  to  lead  to  per- 
manent mischief  than  the  worse  gouty  seizures. 

Anorexia,  thirst,  constipation,  a  high-coloured,  scanty 
urine,  turbid  on  cooling,  are  part  of  the  usual  type.  Severe 
cramps  in  the  legs  may  aggravate  the  discomfort. 

Premonitions,  usually  absent  prior  to  the  first  attack, 
are  almost  the  rule  in  later  ones  in  the  shape  of  disturb- 
ance of  digestion,  '  heart-burn,  acidity,  flatulence,  drowsi- 
ness after  food,  hiccough,  confined  bowels,  loss  of  appetite, 
lowness  of  spirits,  and  a  feeling  of  lassitude.'  The  indi- 
vidual weakness  or  symptom  is  apt  to  assert  itself,  and 
usually  there  is  much  irritability  of  nerves  or  temper. 
The  premonitory  symptoms,  and,  in  particular,  the  fre- 
quent bronchitis,  are  relieved  on  the  advent  of  the  fit 
*  The  urine  before  an  attack  is  usually  scanty  and  highly 


IQO  THE  ACUTE  ARTHRITIC  ATTACK 

coloured,  but  sometimes,  on  the  other  hand,  very  copious 
and  pale.' 

In  spite  of  the  appearances  so  suggestive  of  the  forma- 
tion of  pus,  gouty  inflammation  is  not  followed  by  sup- 
puration. Garrod  doubts  whether  a  first  fit  of  the  gout 
has  ever  been  recorded  in  which  suppuration  took  place. 

Among  the  general  symptoms,  all  of  which  are  regarded 
as  induced  by  the  local  condition,  and  are  not,  as  often 
in  rheumatic  fever,  out  of  proportion  to  the  articular 
trouble,  the  feverishness,  acceleration  of  pulse,  thirst, 
anorexia,  all  vary  with  the  severity  of  the  local  inflam- 
mation. 

The  temperature  of  the  axilla  '  ranges  from  99°  Fahr.  to 
104°  Fahr.,  most  commonly  from  100  to  102  where  many 
joints  are  involved,  and  from  99  to  100  where  one  or  two 
only. 

Although  '  intense  heat  of  the  joints  '  is  complained 
of,  the  surface  thermometer  does  not  record  a  marked 
rise. 

The  skin,  at  first  dry,  becomes  moist  without  ever  pre- 
senting the  heavy  sweats  of  acute  rheumatism. 

The  tongue  is  furred ;  anorexia,  thirst,  and  often  con- 
stipation, with  obvious  portal  congestion,  occur.  As  a 
whole  the  dige'^tive  system  is  much  upset,  though  in  a 
few  cases  it  escapes.  The  enlargement  of  the  liver  may 
be  purely  temporary,  or  may  have  existed  as  one  of  the 
astiological  factors  of  gout. 

The  pain  is  characteristic.  By  those  who  are  in  a 
position  to  compare,  it  is  felt  to  be  different  from  other 
pains,  whether  rheumatic  or  from  injury.  '  It  often  pre- 
cedes the  other  signs  of  inflammation,  is  more  localized, 
and  generally  at  first  confined  to  a  spot  on  the  side  of 
the  joint ;  whereas  in  acute  rheumatism  the  pain  extends 
throughout  the  whole  articulation.'     Sir  A.   Garrod  has 


THE  ACUTE  ARTHRITIC  ATTACK  1-91 

met  with  cases,  now  so  common,  of  a  first  attack  of  gout 
in  which  the  severity  of  the  pain  was  not  in  proportion  to 
the  apparent  signs  of  inflammation. 

The  following  is  Sydenham's  description  of  the  pain  : 

*  When  the  disease  is  confirmed,  the  ligaments  of  the 
ankle-bones  feel  as  if  wrenched  or  squeezed  by  a  strong 
hand  when  the  patient  stretches  himself  of  a  morning. 
At  times,  without  any  stretching  at  all,  there  is  this  pain, 
and  just  as  the  patient  is  going  to  sleep  he  feels  as  if 
the  ankle-bones  were  suddenly  crushed  by  a  heavy  blow, 
and  he  wakes  with  a  cry.  The  tendons  of  the  muscles 
of  the  ankle  are  seized  with  a  pain  so  intense  that  if  it 
were  permanent  it  would  wear  out  human  patience.  .  .  . 

'  Sometimes  the  thigh  feels  as  if  a  weight  were  attached 
to  it,  without,  however,  any  intolerable  pain.  It  descends, 
however,  to  the  knee,  and  then  the  pain  is  intense.  It 
checks  all  motion,  nails  the  patient  down  to  his  bed, 
and  will  hardly  allow  him  to  change  his  posture  a  hair's 
breadth.  .  .  .  The  least  contrary  movement  causes 
pain,  which  is  tolerable  only  in  proportion  as  it  is 
momentary.  This  movement  is  one  of  the  great  troubles 
in  gout,  since  with  perfect  quiet  the  agony  is  just  toler- 
able. .  .  .  One  thing,  however,  is  constant  :  the  pain 
increases  at  night  and  remits  in  the  morning.' 

'  The  mind  suffers  with  the  body,  and  which  suffers  most 
it  is  hard  to  say.  So  much  do  the  mind  and  the  reason 
lose  energy  as  energy  is  lost  by  the  body,  so  susceptible 
and  vacillating  is  the  temper,  such  trouble  is  the  patient 
to  others  as  well  as  to  himself,  that  a  fit  of  gout  is  a  fit 
of  bad  temper.  To  fear,  to  anxiety,  and  to  other  passions, 
a  gouty  patient  is  the  continual  victim,  while,  as  the 
disease  departs,  the  mind  regains  tranquillity.' 

The  oedema  is  also  characteristic,  and  a  valuable  guide 
in  the   diagnosis  from  rheumatism,   in  which  it   is  quite 


192  THE  ACUTE  ARTHRITIC  ATTACK 

exceptional,    although    the    pitting     cannot    be     readily 
obtained  until  the  acute  tension  is  lessened. 

The  desquamation,  which  is  often  preceded  by  much 
itching,  occurs  after  the  acute  symptoms  have  subsided, 
and  is  thought  by  Garrod  to  be  induced  by  the  previous 
oedema. 

As  suggesting  a  derivation  of  the  cedema  from  the 
toxic  influence  of  some  blood  impurity,  Garrod  notices 
the  local  oedema  also  observed  in  gonorrhoeal  rheumatism 
and  in  pyaemia. 

This  is  Sydenham's  description  of  some  of  the  symptoms 
which  have  been  enumerated  : 

'  For  the  first  fourteen  days  the  urine  is  high-coloured, 
has  a  red  sediment,  and  is  loaded  with  gravel.  Its  amount 
is  less  than  a  third  of  what  the  patient  drinks.  During 
the  same  period  the  bowels  are  confined.  Want  of  appetite, 
general  chills  towards  evening,  heaviness,  and  a  trouble- 
some feeling  at  the  parts  affected,  attend  the  fit  through- 
out. As  the  fit  goes  off,  the  foot  itches  intolerably,  most 
between  the  toes ;  the  cuticle  scales  off,  and  the  feet 
desquamate  as  if  venomed.  The  disease  being  disposed 
of,  the  vigour  and  appetite  of  the  patient  return,  and  this 
in  proportion  to  the  violence  of  the  last  fits.  In  the 
same  proportion  the  next  fit  either  comes  on  or  keeps  off. 
Where  one  attack  has  been  sharp,  the  next  will  take  place 
that  time  next  year,  not  earlier.' 

A  diagnosis  between  acute  gout  and  acute  rheumatism 
is  not  always  easy.  In  the  past  mistakes  have  undoubtedly 
occurred.  It  is  important  to  remember  this  circumstance 
in  connection  with  some  of  the  older  records  of  metastasis 
of  gout  to  the  viscera,  and  particularly  to  the  heart. 

In  Garrod's  experience  the  formation  of  chalk-stones  on 
a  large  scale  may,  but  this  is  the  exception,  follow  soon 
after  the  acute  attack.     '  Permanent  stiffness  or  complete 


THE  ACUTE  ARTHRITIC  ATTACK  193 

ankylosis  may  result  from  a  first  attack,  even  though  unac- 
companied with  much  local  inflammation  or  enlargement.' 

The  Duration  of  the  Attack. — According  to  Sydenham, 
'  In  strong  constitutions,  where  the  previous  attacks  have 
been  few,  a  fortnight  is  the  length  of  an  attack.  With 
age  and  impaired  habits,  gout  may  last  two  months. 
With  very  advanced  age,  and  in  constitutions  very  much 
broken  down  by  previous  gout,  the  disease  will  hang  on 
till  the  summer  is  far  advanced,' 

'  Now,  a  series  of  lesser  fits  like  these  constitute  a  true 
attack  of  gout,  long  or  short,  according  to  the  age  of  the 
patient.  To  suppose  that  an  attack  two  or  three  months 
in  length  is  all  one  fit  is  erroneous.  It  is  rather  a  series 
of  minor  fits.  Of  these  the  latter  is  milder  than  the 
former,  so  that  the  peccant  matter  is  discharged  by 
degrees,  and  recovery  follows.' 

THE  CHARACTER  OF  THE  ACUTE  LOCAL  LESIONS. 

The  aspect  of  the  local  inflammation  is  that  of  a  phleg- 
mon ;  but  though  vascular  changes  occur,  they  are  not 
due,  so  far  as  we  know,  to  any  infective  inflammatory 
process.  Rarely  do  we  hear  of  any  suppuration  in  or 
around  an  acutely  gouty  joint.  On  the  other  hand,  the 
vascular  reactions  are  singularly  prominent,  and  as  sudden, 
as  rapid,  and  as  severe,  as  in  any  common  inflammation 
accompanied  with  diapedesis.  The  non-occurrence  of 
phlegmonous  diapedesis  is  also  a  feature  of  rheumatic 
arthritis,  which  differs  from  the  gouty  both  in  its  aspect, 
in  the  obvious  degree  of  the  lymphatic  disablement,  and 
in  the  absence  of  subsequent  desquamation,  an  almost 
invariable  sequel  in  gout.* 

*  Scudamore  states  that,  of  234  cases,  78  had  never  presented  this 
sign. 

13 


194  THE  JOINTS  AFFECTED 

To  what  extent  and  in  what  manner  the  arthritic 
attack  may  influence  the  constitutional  state  of  the 
patient  is  a  question  upon  which  cHnical  evidence  is 
conflicting.  Sydenham  regarded  the  attack  as  the  means 
of  clearing  the  system  of  the  materia  peccans,  and  Garrod 
regards  the  local  inflammation  as  able  to  destroy  part  of 
the  local  accumulation  of  biurate.  In  other  cases  the 
opposite  result  is  observed. 

At  any  rate,  no  fixed  proportion  seems  to  exist  between 
the  severity  of  the  arthritic  seizure  and  the  constitutional 
consequences.  These  in  some  fortunate  instances  will  not 
appear  after  a  single  sharp  attack  or  a  series  of  attacks, 
whilst  profound  changes  are  observed  in  many  whose 
attacks  have  never  been  so  severe,  though  more  frequent. 

THE  JOINTS  AFFECTED. 

The  great  toe  is  the  first  to  suffer  in  a  great  majority  of 
cases.  A  satisfactory  explanation  of  this  striking  liability 
has  never  been  given.  It  has  been  suggested  that,  of  all 
joints,  it  is  worked  hardest,  or,  at  any  rate,  most  con- 
stantly ;  yet,  as  in  hard-working  labourers  it  is  not  the 
subject  of  gout,  it  might  even  be  argued  that  in  most 
patients  it  has  not  been  worked  hard  enough. 

Moreover,  after  all  said,  each  joint  in  our  body  is  made 
for  the  express  purpose  of  being  used,  but  this,  one  of  the 
most  active  of  our  nether  joints,  is  rarely  allowed  the  full 
freedom  which  it  claims.  None  of  our  joints  is  so  much 
hampered  as  that  of  the  toe  by  shoe-leather.  Even  the 
sandal  of  the  ancients  must  have  interfered  with  its  full 
flexion.  Its  exercise  is  taken  under  adverse,  and  too  often 
painful,  restrictions  as  regards  room  and  proper  circula- 
tion. Few  make  a  point  of  giving  it  at  times  a  hygienic 
holiday. 


THE  JOINTS  AFFECTED  195 

Sir  A.  Garrod  mentions  its  abundant  fibro  -  vascular 
tissues,  its  remoteness  from  the  heart,  its  exposed  position, 
rendering  it  obnoxious  either  to  direct  violence  or  to  the 
danger  of  false  steps — and  to  various  injuries  of  which  he 
has  traced  the  results  in  the  bodies  of  those  who  had 
never  had  the  gout. 

We  are  reminded  also  of  the  peripheral  position  and  the 
heavier  column  of  blood,  which  favour  local  congestions. 
All  these  influences  had  been  noticed  as  possible  deter- 
mining agencies  by  Boerhaave  and  Van  Swieten. 

The  great  toe  may  be  the  first  joint  affected  because 
of  its  more  universal  and  constant  use  even  by  those 
whose  hands  are  relatively  inactive,  and  because  the 
wrenches  and  strains  which  predispose  to  the  gouty 
deposit  are  more  likely  to  occur  when  the  joint  does  not 
work  true,  its  axis  having  been  thrown  out  by  the  con- 
tinued pressure  of  ill-fitting  boots. 

None  of  the  alleged  reasons  are  really  satisfactory,  and 
the  question  remains  one  for  speculation.  Thus,  Sir  A. 
Garrod  reminds  us  of  the  attraction  of  certain  poisons  for 
definite  parts  of  the  body,  and  questions  whether  this 
influence  may  not  have  something  to  do  with  the  early 
selection  of  the  great  toe  by  the  gouty  affection. 

The  order  in  which  the  various  joints  are  successively 
affected  is,  according  to  Garrod  {loc.  cit.,  p.  291),  about 
the  following :  (i)  The  great  toes;  (2)  the  heels ;  (^3)  the 
ankles  ;  (4)  the  knees ;  (5)  the  small  hand-joints ;  (6)  the 
elbows ;  and  lastly,  the  shoulders  and  hips. 

Garrod*  found  that  in  no  more  than  5  per  cent,  were 
other  joints  implicated,  to  the  exclusion  of  the  great  toe  ; 
and  he  quotes  Dr.  Braun's  forty  cases,  thirty-six  of  which 
occurred  in  the  toe,  two  in  the  heel,  one  in  the  knee,  and 
one  in  the  hip  also. 

*  Loc.  cit.,  p.  18. 


196  THE  JOINTS  AFFECTED 

Sir  Charles  Scudamore*  gives  a  table  of  516  cases,  in 
which  the  part  first  affected  was  noted.  One  or  both 
great  toes  alone  suffered  in  341,  or  nearly  two-thirds ;  in 
373  the  great  toe  was  attacked,  together  with  some  other 
part.  In  less  than  twenty  cases  out  of  the  whole  was  the 
lower  extremity  not  included  among  the  parts  affected.! 

Among  the  localizing  factors,  besides  the  predisposing 
occurrence  of  previous  mechanical  damage,  Garrod  lays 
great  stress  on  cold.  The  hip -joint,  which  is  rarely 
affected,  is  by  its  proximity  to  the  trunk  kept  at  an 
evenly  warm  temperature  ;  that  of  the  knee,  which  suffers 
much,  is  frequently  depressed,  and  that  of  the  foot  yet 
more  often. 

He  notices  that  in  the  case  of  more  superficial  deposits 
the  spots  selected  are  also  those  of  a  relatively  sluggish 
circulation.  The  ear  is  specified  as  an  instance  of  both 
peculiarities. 

The  extension  of  the  process  from  the  single  joint 
originally  attacked  to  many  joints  may  be  regarded  in  the 
light  of  an  overflow  of  the  accumulating  store  of  urates 
from  the  parts  which  first  attracted  it  to  others  still  un- 
encumbered. 

Chemical  reaction  is  probably  an  important  localizing 
agent.  In  explanation  of  the  special  liability  of  particular 
tissues,  '  the  ligaments,  cartilages,  and  others  closely 
allied,'  Garrod  suggests  that,  in  addition  to  their  possess- 
ing but  little  vascularity,  they  probably  are  less  alkaline 
than  many  other  tissues,  and  certainly  less  alkaline  than 
the  blood  itself. 

*  Quoted  by  Garrod,  loc.  cit.,  p.  17. 

t  The  following  observation  of  Scudamore  has  a  practical  bearing  : 
'  I  find  that  in  examples  of  hereditary  gout  the  great  toe  has  been  the 
situation  first  chosen,  and  that  the  most  remarkable  exceptions  have 
been  in  those  persons  who  have  wholly  acquired  the  disease.' 


CHAPTER  XXIII. 

THE   PROGRESS   OF   GOUT.— CHRONIC    GOUT 
AND  GOUTY  CACHEXIA. 

The  original  gouty  attack  may  never  be  followed  by 
another.  The  mode  of  treatment  and  the  mode  of  life 
influence  the  result.  A  strong  predisposition  will,  how- 
ever, expose  some  individuals  to  constant  recurrences  on 
the  slightest  provocation.  Sydenham  had  these  in  mind 
when  he  wrote :  *  Up  to  a  certain  time  the  gout  comes  on 
towards  the  end  of  winter,  lasts  for  two  or  three  months, 
and  retires  regularly.  Afterwards,  however,  it  lasts 
throughout  the  whole  year,  except  only  the  hottest 
months  of  the  summer.  Furthermore,  the  longer  the 
attack  in  general,  the  longer  is  each  individual  fit.  In- 
stead of  a  day  or  two,  they  last  a  fortnight.  Instead  of 
the  feet,  they  attack  any  joint  indifferently.  Lastly,  on 
the  first  or  second  day  after,  the  patient,  besides  the  pain, 
has  loss  of  appetite  and  general  discomfort.' 

'  Until  the  disease  has  reached  a  certain  degree  of 
severity,  the  patient  enjoys  long  intervals  between  the 
fits,  and  during  these  intervals  good  health.  .  .  .  After  it 
has  attacked  each  foot,  the  fits  become  irregular,  both  as 
to  the  time  of  their  accession  and  duration.' 

The  accuracy  of  this  description  has  been  confirmed  by 
all  observers.  Garrod  states  that  the  autumnal  fit  is  not 
usually  added  until  several   of  the  annual  attacks    have 


198  ^^Hl  CHRONIC  GOUT 


recurred  in  spring.  He  mentions,  however,  exceptional 
cases  '  who  suffer  more  in  summer  than  at  any  other  time 
of  the  year.' 

Thus,  the  individual  clinical  history  of  gout  will  take  very 
different  forms.  It  may  be  limited  to  one  or  two  acute 
attacks  in  the  great  toe,  the  gout  never  passing  into  the 
chronic  stage.  Or  it  may  consist  of  a  series  of  seizures 
occurring  at  first  at  distant  intervals  and  timed  by  the 
seasons,  but  gradually  becoming  more  and  more  frequent 
and  irregular  in  their  appearance.  Still,  as  pointed  out 
by  Garrod,  this  frequency  may  not  be  associated  with  any 
wide  distribution  of  the  joint  affection,  nor  with  extensive 
damage  to  the  joint  structures  ;  and  the  liability  may  last 
only  for  a  period  of  years,  and  ultimately  cease  before  old 
age.* 

A  totally  different  picture  is  afforded  by  the  more  severe 
types  of  chronic  gout,  the  deforming  and  crippling 
arthritic  varieties,  and  gouty  cachexia.  It  is  not  un- 
common for  these  forms  of  affliction  to  be  combined  in 
the  same  subject ;  indeed,  the  question  has  never  been 
settled  as  to  whether  the  cachexia  arises  from  the  joint 
disease,  or  whether  the  joints  suffer  most  because  of  the 
constitutional  decay.  At  any  rate,  an  inevitable  down- 
ward progression  is  obvious  in  both  sets  of  cases. 

The  Crippling  Form  of  Chronic  Gout. — It  suffices  for 
an  early  acute  attack  to  have,  as  rarely  happens,  set  up 

*  The  mitigation  of  the  arthritic  symptoms  of  gout  with  the  decline 
of  hfe  has  long  been  known.  Sydenham  refers  to  it  in  the  following 
words  :  'After  many  torments,  when  death  is  about  to  relieve  the 
patient,  the  fits  become  milder.  .  .  .  Then,  instead  of  the  usual  pain, 
there  is  uneasiness,  pain  in  the  stomach,  weariness,  and  sometimes  a 
tendency  to  diarrhoea.  These  symptoms  ease  the  pain.  The  pain 
abates  these  symptoms.  .  .  .  When  gout  has  gone  on  for  many  years, 
the  fits  grow  easier,  and  the  patient  is  worn  out  by  weakness  rather 
than  by  pain.' 


CHRONIC  GOUT  199 


ankylosis  in  one  of  the  joints  of  the  lower  limb  to  hence- 
forth introduce  into  the  patient's  clinical  history  a  new 
factor — that  of  restricted  movement,  or  even  of  relative 
immobility.  This  is  in  all  cases  a  serious  aggravation  of 
any  previous  predisposition  to  the  disease,  distinctly 
favouring  its  further  developments.  It  is  the  more  re- 
markable that  many  thus  afflicted  do  not  go  from  bad  to 
worse,  but  maintain  a  comparative  level  of  general  health 
and  relative  freedom  from  local  manifestations.  With 
others,  probably  of  less  robust  health  originally,  or  less 
careful  of  the  rules  of  hygiene,  the  results  are  painful  to 
witness  ;  more  and  more  joints  become  implicated  and 
useless,  until  the  patient's  life  is  a  burden. 

Sydenham  gives  a  graphic  account  of  the  crippling 
effects  of  gout :  '  Sometimes  it  distorts  the  fingers  ;  then 
they  look  like  a  bunch  of  parsnips,  and  become  stiffened 
and  immovable.  This  is  from  the  deposit  of  chalk-stones 
about  the  ligaments  of  the  knuckles.  The  effect  of  this  is 
to  destroy  the  skin  and  cuticle.  Then  you  have  chalk- 
stones  like  crabs'  eyes  exposed  to  view,  and  you  may  turn 
them  out  with  a  needle.  Sometimes  the  morbific  matter 
fixes  on  the  elbows,  and  raises  a  whitish  tumour  almost  as 
large  as  an  egg,  which  gradually  grows  red  and  inflamed. 

'  Eventually  the  limbs  become  drawn  up  and  contracted. 
.  .  .  The  more,  too,  the  patient  strives  to  walk,  under 
the  idea  of  strengthening  his  feet,  and  thereby  rendering 
them  less  liable  to  the  disease,  the  more  likely  is  the 
peccant  matter,  which  has  never  yet  been  fully  dis- 
charged, to  be  thrown  upon  the  inward  parts.  Herein  is 
the  great  danger.' 

Progressive  failure  of  health  is  largely  explained  in  the 
case  of  the  crippled  person  by  the  discomfort,  the  pain, 
and  the  mental  disappointment,  and,  above  all,  by  the 
loss  of  that  minimum  of  exercise  which  is  the  preventive 


200  THE  VARIETIES  OF  CHRONIC  GOUT 

of  gout,  and  may  even  sometimes  be  regarded  as  its 
cure. 

Sir  A.  Garrod's  cases  of  chronic  gout  presented  a  con- 
siderable amount  of  uric  acid  in  the  blood. 

The  urine  of  chronic  gout  is  described  by  Garrod  as 
being  '  rather  paler  than  healthy  urine,  of  lower  density, 
and  increased  in  quantity.  The  amount  of  urea,  except 
in  extreme  cases,  remains  much  as  in  health,  the  character 
of  the  diet  being  taken  into  consideration.  The  uric  acid 
is  very  much  diminished,  and  liable  to  be  excreted  in  an 
intermittent  manner.  A  small  amount  of  albumen  is 
very  frequently  present.  The  occurrence  of  deposits  in 
the  urine  is  not  common ;  they  occasionally  fall  during 
the  cooling  of  the  fluid,  either  in  the  form  of  urate  of  soda 
or  as  rhombs  of  uric  acid,  more  or  less  coloured.' 

THE   VARIETIES  OF  CHRONIC  GOUT. 

Sir  Dyce  Duckworth,*  in  his  masterly  analysis  of  this 
subject,  describes,  in  addition  to  gouty  cachexia,  two 
main  varieties  of  chronic  gout — the  '  tophaceous '  and  the 
'  deforming.' 

Tophaceous  Gout,  or  Chalky  Gout,  is  characterized  by 
uratic  deposits,  often  of  great  size,  in  the  neighbourhood 
of  the  joints,  distending  the  skin,  which  may  give  way 
and  exude  a  creamy  fluid.  This  secondary  softening  of 
the  deposit  is  usually  not  due  to  suppuration,  though  in 
broken-down  constitutions  abscess  may  form,  the  dis- 
charge then  consisting  of  pus  in  addition  to  the  sodium 
and  calcium  urate,  to  calcium  phosphate  and  sodium 
chloride,  which  are  the  usual  constituents.  The  outflow 
of  urates  may  be  considerable ;  whilst  it  lasts,  and  for 
some  time  afterwards,  the  patient  seems  to  be  protected 
against  fresh  articular  attacks. 

*  Loc.  cii.,  p.  2S4  et  seq.. 


THE  VARIETIES  OF  CHRONIC  GOUT  201 

The  tophi  may  be  in  direct  communication  with  the 
joint,  or,  as  in  the  case  of  the  subcutaneous  infiltrations 
and  of  bursal  tophi,  situated  at  a  distance  from  it. 

The  skin  in  the  vicinity  of  the  tophi  is  thin,  glossy, 
and  often  purplish  from  venous  congestion. 

Tophi,  according  to  Duckworth,  and  especially  those 
in  the  ear,  may  precede,  even  by  some  years,  the  arthritic 
attacks ;  or,  on  the  other  hand,  they  may,  even  without 
the  occurrence  of  ulceration,  partly  disappear  under  the 
influence  of  repeated  arthritic  attacks,  fresh  tophi  being 
developed. 

Tophaceous  gout  is  more  common  in  the  male  sex. 
It  is  usually  associated,  sooner  or  later,  with  gouty  renal 
disease. 

Chronic  Deforming  Gout  is  largely  made  up,  according 
to  Duckworth,  of  arthritic  changes  analogous  to  those  of 
osteo-arthritis,  with  a  minimum  of  uratic  infiltration. 
Deformity,  deflection,  dislocation,  ankylosis,  true  or  false, 
are  associated  with  overgrowth  of  cartilage  and  of  bone, 
erosion,  uratic  incrustation,  moderate  synovial  effusion, 
and  crackling  on  movement,  though  none  of  the  charac- 
teristic changes  are  so  extreme  as  in  osteo-arthritis.  The 
extent  and  rapidity  of  the  local  changes  does  not  bear 
any  constant  relation  to  the  severity  or  frequency  of  the 
paroxysmal  attacks.  Individual  peculiarity  largely  in- 
fluences the  articular  degenerations.  Implication  of 
bursae  is  common,  and  cutaneous  uratic  infiltrations  may 
occur.  The  crippling  effect  is  great,  especially  when  the 
knee  or  ankle  is  affected. 

Duckworth  associates  with  the  description  of  this  form 
that  of  the  chronic  painful  affections  of  tendons  and  fascicB, 
particularly  those  of  the  foot  (heel  and  tendo  Achillis, 
plantar  fascia,  tarsus,  etc.)  and  the  extreme  deflections  of 
digits  and  toes. 


GOUTY  CACHEXIA 


Analogous  chronic  changes,  again,  are  those  limited  to 
the  knotty  enlargement  of  the  small  joints,  and  to  the 
formation  of  Heberden's  nodules,  and  usually  (especially 
in  women,  who  are  more  subject  to  them)  connected  with 
a  history  of  visceral  and  nervous  rather  than  of  articular 
symptoms,  and  in  that  sense  not  strictly  to  be  included 
under  the  heading  of  chronic  gout.  Duckworth  suggests 
incomplete  gout  as  their  proper  category. 

In  the  entire  group,  although  organic  and  particularly 
renal  complications  are  apt  to  occur,  there  is  less 
tendency  than  in  the  tophaceous  group  to  cachexia  and 
to  early  break-down.  Life  may  long  be  spared,  in  spite 
of  some  renal,  cardio-vascular,  and  pulmonary  (emphy- 
sematous) change. 

GOUTY  CACHEXIA. 

Gouty  cachexia  is  the  extreme  expression  of  that  faulty 
metabolism  which  is  at  the  root  of  gout,  and  we  may 
note  that  it  is  not  restricted  to,  though  perhaps  more 
common  in,  those  whose  uratic  deposits  have  been  most 
abundant.  It  is  a  late  development,  except  under  the 
accelerating  influence  of  strong  hereditary  predisposition 
or  of  depression,  which  may  determine  its  advent  in  early 
middle  age.  Duckworth  has  once  exceptionally  seen  it 
in  a  woman  at  forty.  He  traces  the  occurrence  of  cachexia 
either  to  original  frailty  of  constitution  or  to  that  which 
is  induced  by  unbridled  indulgence  in  the  predisposed. 
Truly  robust  constitutions  do  not  suffer  in  this  way,  or 
only  late,  though  they  may  have  the  gout  often  and 
severely.  Persistent  energy  of  digestion  and  plentiful 
supplies,  though  they  may  feed  the  gout,  doubtless  ward 
off  the  cachexia. 

In  the  light  of  modern  pathology  we  trace  many  of 
the  varied  symptoms  of  the  condition  in  question  to  the 


GOUTY  CACHEXIA  203 


organic  changes  which  form  its  substratum.  Ultimately 
all  the  tissues  suffer,  as  a  result  partly  of  the  original 
gouty  malnutrition,  but  very  largely  of  the  secondary 
organic  disease. 

In  gouty  cachexia  we  are  obviously  dealing  with  the 
results  of  deep-seated  changes,  which  no  longer  admit 
of  correction,  and  with  deviations  of  nutrition  based  upon 
the  organic  defects,*  and  henceforth  incapable  of  being 
rectified.  The  chief  organic  failures  are  those  connected 
with  the  blood,  with  the  organs  of  digestion,  and  particu- 
larly with  the  stomach  and  liver,  and  with  the  kidney. 

Pallor  is  a  striking  feature  of  the  average  gouty  cachectic 
person.  It  is  probable  changes  in  the  blood  ultimately 
take  place,  though,  as  elsewhere  pointed  out,  anaemia  is 
not  a  characteristic  of  early  gout. 

The  failure  of  digestion  is  greatly  due  to  the  circum- 
stances just  mentioned.  At  an  earlier  date  it  is  in  obvious 
connection  with  hepatic  derangements  "f-  and  nervous  dis- 
turbances. We  need  not  dwell  here  upon  this  aspect  of 
gouty  cachexia. 

The  organic  changes  occurring  in  the  kidney  have 
already  been  discussed,  and  a  great  part  of  the  cachexia 
of  gout  must  be  attributed  to  the  general  results  of  renal 
atrophy,  casting  upon  the  system  a  variety  of  toxic 
substances  in  addition  to  an  unexcreted  balance  of  uric 
acid. 

*  '  The  peccant  matter  lodges  in  the  viscera,  involves  their  struc- 
ture, impairs  the  organs  of  secretion,  leaves  the  blood  stagnant,  thick, 
and  feculent,  prevents  the  discharge  of  the  gouty  matter  on  the 
extremities,  makes  life  worse  than  death,  and  finally  brings  in  death  as 
a  relief — Sydenham,  loc.  cit. 

f  '  Other  symptoms  arise,  piles  amongst  others.  Also  indigestion, 
with  rancid  tastes  in  the  mouth  whenever  anything  indigestible  has 
been  swallowed.  The  appetite  fails,  so  does  the  whole  system.  The 
patient  has  no  enjoyment  of  life.  .  .  .  The  back  and  other  parts 
itch,  most  at  bed-time.' — Sydenham. 


204  GOUTY  CACHEXIA 


The  general  effects  of  renal  toxaemia  are  greatly  inten- 
sified in  the  specially  debilitated  subjects  of  chronic  gout, 
and  the  toxic  tissue-decay  proceeds  rapidly,  with  a  mini- 
mum of  reactionary  growth.  In  this  way  may  be 
explained  the  anaemia,  the  early  fatty  degeneration  of 
the  cardio-vascular  system,  with  all  the  consequences 
implied,  the  atony  of  mucous  membranes,  the  failure  of 
the  glandular  system,  and  the  ultimate  giving  way  of  the 
nervous  functions,  the  cerebral  symptoms  ranging  from 
simple  depression  with  irritability,  to  amnesia,  delusions, 
stupor,  or  coma.  Death  may  occur  from  the  usual  results 
of  combined  renal  and  cardiac  disease,  or  from  the  rupture 
of  a  cerebral  vessel,  or  from  some  intercurrent  acute 
inflammation. 

Tubercular  phthisis,  in  a  small  proportion  of  cases,  is 
a  final  complication  of  advanced  cachexia.  At  this  stage 
gout  does  not  appear  to  exert,  as  in  the  earlier  periods,  a 
prophylactic  influence  against  bacillary  disease.  On  the 
contrary,  the  lesions  of  phthisis  are  apt  to  run  a  more 
than  usually  rapid  course  in  the  unhealthy  tissues  of  the 
gouty  cachectic. 


CHAPTER  XXIV. 

THE    CLINICAL    FEATURES     OF     GOUT     AND 

GOUTINESS   IN    CONNECTION    WITH   THE 

VARIOUS  ORGANS.— AFFECTIONS  OF 

THE  MUCOUS  MEMBRANE. 

Anatomical  evidence  that  uratic  gout  can  affect  internal 
organs  is  almost  absolutely  wanting.  Much  so-called 
'  visceral  gout '  should  strictly  be  termed  '  visceral  disease 
in  the  gouty.'  Clinical  evidence  on  the  contrary  points 
to  a  decided  influence,  peculiar  to  the  gouty  state,  which 
determines  the  onset,  and  modifies  the  course  of  visceral 
affections.  The  association  with  articular  gout  is  often  so 
close  that  '  visceral  gout '  has  been  allowed  currency  as  a 
clinical  expression,  applicable  to  a  limited  number  of 
disorders  ;  but  even  in  these  the  reservation  mentioned 
should  never  be  forgotten. 

Without  attempting  an  elaborate  study  of  so  wide  a 
subject,  we  may  profitably  review  the  more  important 
structures  and  organs  in  respect  of  their  liability  to  gouty 
manifestations,  reserving  for  subsequent  consideration  the 
abarticular  symptoms  of  retrocedent  gout. 

THE  CRITERIA  FOR  THE  GOUTY  NATURE  OF 
SYMPTOMS. 

In  view  of  this,  pathologically  speaking,  insecure 
position,  and  of  the  scepticism  to  which  an  ill-judged  use 


2o6  THE  CRITERION  FOR  GOUT 

of  the  term  '  gout  '  too  often  gives  rise,  it  is  desirable  to 
define  as  closely  as  possible  the  conditions  under  which 
its  employment  is  called  for. 

The  differences  between  so-called  gouty  and  ordinary 
inflammations  occurring  in  the  same  situations  may  be 
such  as  would  appeal  only  to  the  expert.  To  the  general 
physician,  from  whose  standpoint  these  pages  are  written, 
their  gouty  nature  is  usually  rendered  sufficiently  obvious 
by  the  constitutional  context,  and  to  the  specialist  their 
peculiarities  are  sufficiently  striking  to  lead  to  a  suspicion 
of  their  constitutional  cause ;  and  in  either  case  their 
proper  treatment  is  the  treatment  of  the  gout  upon  which 
they  depend. 

The  gouty  joint  bears  its  own  diagnosis  written  large, 
but  no  distinctive  feature  attaches  to  the  abarticular 
troubles,  all  of  which  may  own  various  other  causes. 
There  is  an  inherent  difficulty  in  the  attempt  to  prove 
as  gouty  any  abarticular  symptoms,  and  especially  the 
visceral.  Many  of  the  latter  are  in  themselves  subjective, 
mysterious,  and  without  tangible  lesion.  The  few  in 
which  definite  structural  changes  are  perceptible,  as,  e.g., 
the  effusion  into  a  tunica  vaginalis,  or  the  rales  and  rhonchi 
of  a  congestive  bronchial  attack,  or  the  visible  changes  in 
the  skin  of  an  eczema,  are  therefore  specially  valuable  as 
definite  objects  for  study.  Still,  everywhere  our  evidence 
is  clinical — sit  venia  verbo — rather  than  mathematical. 
As  physicians  we  are  convinced,  but  we  may  fail  to  carry 
conviction  into  the  patient's  mind. 

Our  available  criteria  are  presimiptive  and  retrospective, 
resting  upon  information  as  to  the  mode  of  origin  of  the 
abarticular  symptoms,  and  upon  observation  as  to  their 
disappearance  under  treatment,  or  after  the  occurrence  of 
an  articular  outbreak.  These  are  the  criteria  which, 
carefully  handled,  are  of  most  value.     The  ynode  of  onset 


GOUTY  LARYNGITIS  207 

may  provide  strong  presumptive  evidence,  especially  in 
the  absence  of  any  other  explanation.  A  definite  and 
immediate  alternation  with  an  acute  articular  attack 
possesses  yet  greater  weight  of  proof,  especially  if  the 
alternation  should  be  of  the  repeating  type,  the  dispelled 
abarticular  symptoms  returning  again  after  a  suppression 
of  the  arthritis. 

I. 

AFFECTIONS    OF    THE    RESPIRATORY    MUCOUS    MEM- 
BRANE:   GOUTY  LARYNGITIS,    TRACHEITIS, 
BRONCHITIS. 

Local  gouty  manifestations  have  often  been  traced  to 
some  local  irritation.  This  causation  is  well  illustrated  in 
the  mucous  membranes.  Those  membranes  suffer  most 
which  are  either  relatively  unprotected  or  liable  to 
definite  temporary  over-stimulation. 

The  frequent  association  between  gout  and  respiratory 
affections,  long  noted  by  physicians,  and  partly  explained 
by  the  prevalence  of  gout  and  of  a  variable  climate  in 
this  country,  bears  out  the  rules  as  to  the  excessive 
vulnerability  of  gouty  tissues,  and  the  ready  production 
of  gouty  manifestations  on  relatively  slight  irritation,  and 
as  to  the  predominant  nervous  type  of  the  symptoms. 
The  genuineness  of  the  gouty  relationship  of  these 
affections  has  not  often  been  contested,  but  the  closeness 
of  their  association  with  gout  varies,  and  likewise  its  type, 
as  will  be  seen  in  bronchitis,  the  chief  and  most  prevalent 
among  them.  The  affections  of  the  higher  air-passages 
alone  afford  us  some  insight  into  the  changes  in  the 
mucous  membrane. 

A  gouty  laryngitis  in  the  strictest  sense,  i.e.,  associated 
with  obvious  deposition  of  urates,  sometimes  occurs. 
Reported  instances  of  this    kind  are  rare.     Deposits  of 


2o8  GOUTY  TRACHEITIS 

urates  have  been  observed  by  Garrod*  on  the  arytenoids, 
by  Virchowt  on  the  right  vocal  cord,  by  LittenJ  in  the 
crico-arytenoid  Hgaments  and  joints,  by  Norman  Moore§ 
in  both  vocal  cords,  and  by  Brooke  ||  in  connection  with 
rigidity  of  the  vocal  cords. 

The  occasional  occurrence  of  these  changes  justifies  the 
inference  that,  at  least  in  the  larynx,  where  fibrous  tissues 
abound,  the  condition  which  we  call  gouty  may  be  con- 
nected with  actual  deposition  of  biurate. 

Garrodli  was  led  to  infer  the  existence  of  a  similar  con- 
dition and  of  rigidity  of  the  articulations  in  a  case  of 
inveterate  gout,  in  which  partial  and  then  absolute 
aphonia,  finally  combined  with  dysphagia,  were  observed. 

The  common  form  of  gouty  laryngitis  is  confined  to 
changes  in  the  mucous  membrane,  analogous,  so  far  as 
we  know,  to  the  pharyngeal  condition  described  as  gouty. 
Undue  congestion  is  its  prominent  feature,  and  with  it 
more  or  less  swelling.  The  congestion  may  extend  to  the 
vocal  cords.  The  symptoms  of  hoarseness,  irritation, 
cough,  scanty  and  occasionally  blood-stained  expectora- 
tion, proceed  unchecked  so  long  as  the  cause  is  not  under 
control.  Even  climatic  treatment,  whilst  mitigating  the 
trouble,  will  not  always  cure  it ;  and  it  is  much  intensified 
by  unsuitable  atmospheric  conditions. 

Gouty  tracheitis  has  not  been  often  described  as  a 
separate  affection,  though  often  associated  with  gouty 
laryngitis  or  with  gouty  bronchitis.  The  appearances 
and  the  symptoms  do  not  differ  from  those  of  ordinary 
tracheitis,  unless,  perhaps,  in  the  greater  irritation  of 
cough  and  the  more  than  usually  scanty  secretion. 

*  Loc.  cit.^  p.  452.  f  '  Archiv.,'  vol.  xliv. 

%  Virchow's  'Arch.,'  vol.  Ixii.,  p.  132  (quoted  by  Duckworth,  p.  85). 

§  '  Pathological  Society's  Transactions,'  xxxiii. 

!|  Medical  Times  and  Gazette,  1871  (cf.  Rendu,  p.  108). 

H  Loc.  cit.,  p.  452. 


GOUTY  BRONCHITIS  209 

The  Gouty  Bronchial  Affections. — So  common  are  the 
bronchial  compHcations  that  the  gouty  connection  has 
been  dwelt  upon  by  most  writers  on  diseases  of  the  chest. 
Laennec,  Andral,  Stokes,*  Greenhowf  all  refer  to  it,  as 
well  as  do  the  writers  on  gout. 

Strict  evidence  of  the  occurrence  of  uratic  deposits  in 
connection  with  the  bronchi  is  not  forthcoming ;  but  sputa 
containing  uric  acid  have  been  described  by  Lecorche 
and  by  Dr.  J.  W.  Moored  among  others,  and  may  have 
been  derived  from  the  bronchi,  though  more  probably 
from  the  larynx. 

The  intensity  of  the  bronchitis  presents  three  degrees  : 
acute  bronchitis,  chronic  bronchial  catarrh,  and  mere 
irritability  of  the  tubes  not  amounting  to  bronchitis.  Its 
relation  to  the  gouty  symptoms  may  be  direct  or  vicarious. 
Thus,  bronchitis  may  accompany  the  arthritic  symptoms, 
it  may  replace  them  in  any  given  case,  or  it  may  alternate 
with  them  in  hereditary  transmission.  Lastly,  its  special 
feature  is  the  presence  of  a  nervous  or  spasmodic  factor. 

A  cute  gouty  bronchitis  is  sometimes  extremely  severe,  and 
in  the  subjects  of  inveterate  gout,  especially  when  renal 
changes  have  occurred,  or  in  the  aged,  it  may  be  fraught 
with  danger.  As  a  rule,  the  urgency  of  the  bronchial 
symptoms  bears  an  inverse  ratio  to  that  of  the  arthritic, 
the  latter  tending  to  remit  with  the  bronchial  exacerba- 
tions. Occasionally,  however,  the  bronchitis  is  part  of 
the  fit  of  gout ;  but  much  more  often  it  is  either  a  pre- 
monitory affection,  abating  somewhat  suddenly  on  the 
advent  of  the  latter,  or  it  breaks  out  on  the  abrupt  cessation 
of  articular  pains.     In  both  cases  it  is  often  accompanied 

"*  Cf.  '  Diseases  of  the  Chest,'  1837,  pp.  84,  90^  91. 
\  '  On  Bronchitis  and  the  Morbid  Conditions  connected  with  it,' 
second  edition,  1878  ;  also  on  '  Gouty  Bronchitis,'  Lancet,  1867. 
J  Irish  Hospital  Gazette,  July,  1863  (quoted  by  Duckworth). 

14 


GOUTY  BRONCHITIS 


with  great   constitutional   disturbance,  hepatic    derange- 
ment, and  irregularity  of  the  heart's  action. 

The  dyspnoea  is  aggravated  by  the  attendant  pulmonary 
congestion,  which  may  be  evidenced  by  the  staining  of 
the  sputa,  and  by  the  conjunction  of  fine  bronchial  rales  ; 
and  emphysema  generally  underlies  the  bronchitis  of  the 
older  subjects,  and  adds  to  its  gravity. 

Subacute  gouty  bronchitis  and  chronic  gouty  bronchitis  are 
proverbially  troublesome  and  obstinate.  They  belong 
specially  to  the  phase  described  as  '  goutiness,'  occurring 
more  commonly  in  the  intervals  than  during  the  arthritic 
seizures.  The  state  of  the  mucous  membrance,  as  origin- 
ally described  by  Laennec,*  may  be  inferred  from  the 
symptoms,  viz.,  irritative  and  painful  cough,  considerable 
oppression,  and  a  scanty  '  pearly '  expectoration.  '  Dry 
bronchial  catarrh '  is  the  name  which  he  gave  to  it. 
Analogous  clinical  features  belong  to  gouty  laryngitis  and 
pharyngitis,  and  we  are  led  to  suspect  in  the  bronchial 
membrane  similar  changes  to  those  which  may  be  seen 
in  those  situations. 

The  gouty  character  of  this  affection  has  occasionally 
been  called  in  question,  in  spite  of  the  cogent  reasons 
upon  which  the  prevailing  opinion  is  based.  Most 
striking  of  all  are  the  marked  alternations  seen  in  some 
subjects  with  arthritic  seizures,  and  the  decided  relief 
afforded  by  treatment  capable  of  controlling  the  gout. 
Scarcely  less  important  are,  in  some  cases,  the  associa- 
tion, in  others  the  alternation,  with  it  of  cutaneous 
eruptions,  such  as  are  observed  with  great  frequency  in 
gouty  states,  and  particularly  of  an  urticarial  rash,  of 
eczema,  or  of  psoriasis.  Habitually  the  cutaneous  and 
the  bronchial  symptoms  replace  each  other,  but  their 
combination  is  not  uncommon. 

*  'Auscultation  M^d.,'  i.,  p.  171  ;  2^™=  ^dit. 


GOUTY  BRONCHITIS 


It  is  also  significant  that  the  tendency  to  a  form  of 
bronchitis  indistinguishable  from  the  gouty,  and  capable  of 
alternating  with  the  characteristic  rashes,  is  apt  to  be 
inherited  from  gouty  parents,  though  articular  gout  may 
not  evolve.  Cases  must  have  occurred  in  the  practice  of 
all  physicians  who  have  devoted  attention  to  gout  in 
which  bronchitis  accompanied  the  rash  in  its  regular 
seasonal  reappearance  in  spring  and  autumn. 

Simple  irritability  of  the  bronchial  membrane  is  a  third 
degree  in  which  mild  gouty  influences  may  take  effect. 
This  form  belongs  mainly  to  the  class  of  inherited  gouti- 
ness. The  bronchial  delicacy  of  many  children,  so  diffi- 
cult to  explain  on  any  other  basis,  is  probably  to  be 
accounted  for  in  this  way.  The  subjects  may  not  develop 
articular  gout  until  late ;  they  may  not  present  the  in- 
veterate type  of  bronchitis  described  above  ;  but  they  are 
constantly  liable  to  slight  bronchial  colds,  often  of  short 
duration,  and  to  laryngeal  irritation  upon  trivial  exposure. 

The  Expectoration  in  Gouty  Bronchitis. — A  clinical  feature 
of  importance,  though  not  restricted  to  gouty  bronchitis, 
is  the  frequent  occurrence  of  Charcot-Leyden  crystals. 

According  to  the  most  recent  observations,  these  are 
a  phosphatic  combination  of  spermin,  itself  a  derivative 
of  nuclein,  and  they  are  intimately  associated  with  a  pro- 
liferation of  leucocytes.  This  peculiarity  of  the  sputum 
might  by  some  be  regarded  as  an  argument  in  favour  of 
the  connection  of  this  form  of  bronchitis  with  gout. 

Gouty  Asthma. — Cases  have  frequently  been  observed  in 
which  genuine  gouty  attacks  have  alternated  with  equally 
genuine  asthmatic  seizures.  Even  those  authorities  who, 
with  Germain  See,  are  sceptical  as  to  the  alleged  causation, 
admit  in  the  majority  of  instances  that  there  is  a  gouty 
form  of  asthma. 

A   larger   group   is   that  of  patients  who  develop  the 


GOUTY  ASTHMA 


respiratory  neurosis    early,   and,  after   a   long   asthmatic 
history,  develop  articular  gout. 

In  a  third  group  are  included  the  hereditary  cases,  in 
which  asthma  in  the  progeny  seems  to  take  the  place  of 
the  articular  gout  of  the  parent.  A  similar  relationship 
has  sometimes  been  reported  between  hay  asthma  and 
gout :  Noel  Gueneau  de  Mussy  has  insisted  upon  this. 
Trousseau,  Murchison,  Garrod,  Durand-Fardel,  Lecorche, 
Duckworth,  have  all  recognised  the  close  association  of 
gout  and  nervous  asthma. 

Laennec  himself  noted  retrocedent  gout  as  a  cause  of 
asthma,*  and  Trousseau  ('  Clin.  Med.,'  ii.,  p.  377)  gives 
a  case  of  a  child,  aged  five,  a  sufferer  from  asthma  and 
emphysema,  who  at  this  age  had  a  distinct  attack  of  gout, 
and  while  thus  affected  was  free  from  asthma.* 

As  to  the  association,  with  asthma,  of  skin  affections  in 
appearance  identical  with  those  which  occur  in  the  gouty 
state,  we  have,  according  to  Wilson  Fox,f  the  testimony 
of  Trousseau,:]:  of  Andral,§  of  Hyde  Salter,  and  others. 
Von  Waldenburgll  is  also  quoted  by  Wilson  Fox  as 
dwelling  on  this  association,  and  referring  to  its  alterna- 
tion with  the  attacks,  applying  to  this  form  the  name 
'  asthma  herpetiforme.'  Trousseau  had  previously  insisted 
that  the  'herpetic  constitution'  ('dartres,'  gout,  rheu- 
matism, and  haemorrhoids)  might  lead  up  to  asthma. 

The  so-called  ursemic  asthma  is  an  entirely  distinct 
affection,  and  need  not  be  considered  in  this  connection. 

Gouty  Pulmonary  Emphysema.  —  Secondary  emphysema 
is    an    inevitable    result  of  a  long  continuance   of  gouty 

*  These  references  are  given  by  Wilson  Fox,  '  A  Treatise  on 
Diseases  of  the  Lungs  and  Pleura,'  edited  by  Sidney  Coupland,  M.D., 
F.R.C.P.,  1891,  p.  54. 

f  Loc.  cit.,  p.  54.  X  '  Clin.  Med.,'  ii.,  p.  399. 

§  Ibid.,  iii.,  p.  258.  ||  '  Locale  Behandlung,'  etc.,  p.  84. 


GOUTY  PULMONARY  CONGESTION  213 

bronchitis  and  asthma.  A  primary  form  has  also  been 
described,  occurring  independently  of  the  mechanical 
operation  of  bronchitis,  and  traceable  to  the  general 
influence  of  gouty  malnutrition.  Sufficient  reference  has 
been  made  to  it  elsewhere  {cf.  p.  134). 

Gouty  Pulmonary  Congestion  and  Hcemoptysis. — Lecorche,* 
who  devotes  special  remarks  to  these  events,  draws  atten- 
tion to  the  great  liability  to  them  inherent  to  the  gouty 
state  by  reason  of  the  age  and  to  the  coexisting  organic 
lesions,  cardiac,  vascular,  and  renal.  Over  and  above 
merely  secondary  congestions,  he  believes  in  the  existence 
of  a  tendency  to  congestion  peculiar  to  the  gouty  state. 
The  seat  of  the  congestion,  usually  basic,  may  also  be 
localized  at  the  apex.  He  refers  to  the  observation  of 
E.  Collin, f  who  professes  to  recognise  it  by  the  peculiarity 
of  its  rales. 

Huchardij:  has  also  dealt  exhaustively  with  this,  and 
reports  cases  of  severe  recurrent  haemoptysis  in  confirm.ed 
gouty  subjects,  some  of  whom  Barth,  Andral,  and  Gendrin 
had  regarded  as  phthisical.  §  These  cases  probably  belong 
to  the  same  category  as  those  described  by  Sir  A.  Clark, 
to  which  we  have  already  referred  {cf.  p.  130). 

A  gouty  pneumonia  was  ■  admitted  by  Musgrave  and  by 
ancient  authorities,  as  well  as  a  gouty  pleurisy.  Lecorche,|| 
who  does  not  recognise  the  latter,  admits  the  pneumonia, 
and  relates  two  cases  of  his  own  and  one  by  Brissaud  in 
which  a  definite  alternation  with  arthritic  gout  could  be 
traced.     English  authors  have  not  recorded  cases. 

*  Loc.  cit..  p.  319. 

f  '  Du  Diagnostic  de  la  Congestion  Pulmonaire  de  Nature  Arthri- 
tique  et  de  son  Traitement,'  1877. 

X  '  Congres  de  I'Assoc.  Frang.  pour  I'Avancement  des  Sciences,' 
1883. 

§  Lecorche,  loc.  cit.,  p.  322.  ||  Ibid.,  p.  324. 


214  GOUTY  PHARYNGITIS 


11. 

THE  MUCOUS  MEMBRANE  OF  THE  ALIMENTARY  TRACT. 
—GOUTY  AFFECTIONS  OF  THE  MOUTH,  FAUCES, 
STOMACH,  AND  INTESTINE. 

The  tongue  is  generally  moist,  and,  according  to  Dick- 
inson,* often  stippled  in  acute  as  well  as  in  chronic  gout. 
It  sometimes  presents  the  characteristic  appearance  of 
glossitis  migrans  or  of  leucoplakia.  In  other  instances  it 
may  be  unduly  red  and  thinly  covered  with  epithelium, 
especially  in  gouty  dyspeptics. 

Heat  and  burning  sensations,  or  severe  neuralgic  dart- 
ing pains,  are  often  part  of  a  gouty  tic  douloureux.  Dis- 
comfort, or  even  severe  pain,  may,  however,  affect  the 
organ  independently  in  gouty  subjects,  and  sometimes 
even,  according  to  Paget,!  give  a  false  alarm  of  cancer. 

Gouty  Pharyngitis. — The  best  opportunity  for  a  study  of 
the  gouty  influences  on  mucous  membranes  is  afforded  by 
the  pharynx.  In  the  previous  history  of  gout  or  gouti- 
ness, in  the  uselessness  of  topical  applications  and  of  the 
usual  treatment,  and  in  the  rapid  relief  obtained  by  a 
treatment  directed  to  the  gout,  we  possess  strong  argu- 
ments for  the  view  that  the  throat  is  liable  to  strictly 
gouty  affections.  The  characteristic  appearances  are  a 
considerable  and  somewhat  dusky  redness  of  the  arches 
and  velum  palati,  of  the  uvula,  and  of  the  pharynx.  The 
entire  membrane,  but  particularly  that  covering  the  uvula, 
is  swollen,  and  apparently  oedematous,  the  fine  detail  of 
its  surface  being  obscured.  The  uvula  is  often  much 
increased  in  size,  and  at  its  extremity  the  swollen  mucous 
membrane  is  apt  to  be  drawn  out  into  a  fine  appendix.  The 

*  Lumleian  Lectures,  1888,  p.  36. 

j-  Quoted  by  Duckworth,  /oc.  cit.,  p.  87. 


GOUTY  AFFECTIONS  OF  THE  STOMACH  215 

pharynx  may  have  been  previously  granular,  and  will  not 
then  present  the  same  degree  of  smoothness  of  surface. 
It  may  be  partly  coated  with  mucous  discharge,  but,  as  a 
rule,  the  appearances  mentioned  are  the  most  striking. 

Tonsillitis  of  a  gouty  character  also  occurs.  In  N. 
Gueneau  de  Mussy'sf  case  the  pharyngeal  follicles  dis- 
charged carbonate  and  urate  of  lime. 

Gouty  Affections  of  the  Stomach. — Sydenham's  observa- 
tion that  gastric  disturbance,  one  of  the  most  frequent 
prodromata  of  acute  gout,  became  more  constant  and 
more  severe  with  the  progress  of  the  affection,  has  been 
confirmed  by  all  later  authorities,  and  a  close  connection 
has  been  universally  admitted  to  exist  between  gout  and 
peculiar  gastric  irritability  and  intolerance. 

Aggravated  dyspepsia  is  also  one  of  the  most  prominent 
symptoms  of  '  goutiness '  in  those  who,  inheriting  the 
predisposition,  have  not  developed  articular  gout.  Garrod 
gives  it  a  place  among  the  abarticular  manifestations  of 
gout,  and  attributes  it  to  the  impurity  of  the  blood  arising 
from  the  impaired  state  of  the  kidneys. 

The  evidence  upon  which  the  alleged  gouty  nature  of 
the  gastric  complications  has  been  based  is  entirely  clini- 
cal. Hitherto  no  uratic  deposits  have  been  recorded  as 
occurring  in  the  stomach,  neither  has  it  been  possible  to 
trace  any  definite  alteration  in  the  mucous  membrane, 
beyond  trifling  changes  in  its  surface  and  the  practically 
inconclusive  occurrence  of  congestion. 

On  the  other  hand,  the  symptoms  are  considerable,  and 
sometimes  grave.  They  involve  acute  derangements  of  all 
the  functions  of  the  organs,  secretory,  motor,  and  sensory. 
Vomiting  and  retching  are  often  severe  and  obstinate,  and 
great  flatulent  distension  and  persistent  hiccough  and 
gastralgia,  associated  with  cramp,  are  also  observed. 

*  Union  Med.,  No.  18,  1856  (quoted  by  Duckworth,  loc.  cit.,  p.  86), 


2i6  GOUTY  AFFECTIONS  OF  THE  STOMACH 

Since  all  these  symptoms  frequently  originate  from 
causes  unconnected  with  gout,  proofs  of  their  gouty  nature 
must  be  sought  in  the  clinical  history  and  in  the  general 
features  of  the  case.  Gout  or  goutiness  has  to  be  diag- 
nosed, and  the  gouty  nature  of  the  symptoms  which  are 
not  distinctive  may  then  be  inferred.  In  the  absence  of 
any  articular  manifestations,  the  inference  is  a  large  one, 
and  has  called  forth  much  scepticism,  such  as  that  of 
Brinton  and  Sir  Thomas  Watson.*  In  other  cases  a 
strong  presumption  may  be  based  upon  the  march  of  the 
symptoms.  The  connection  between  the  gastric  and  the 
articular  manifestations  may  be  one  of  concomitance,  as  in 
the  onset  of  the  acute  arthritis  ;  or  of  alternation,  as  in  the 
case  recorded  by  Sir  A.  Garrod ;  or  of  metastasis.  These 
relations  may  be  regarded  as  the  clinical  tests  of  the  gouty 
nature  of  visceral  attacks  in  general. 

Of  much  diagnostic  value  is  the  strong  nervous  element 
perceptible  in  the  history  of  many  cases.  The  gastric 
attack  is  commonly  induced  by  severe  mental  strain  or 
shock,  and  may  be  immediately  followed  by  an  articular 
seizure.  This  factitious  causation  under  avoidable  cir- 
cumstances is  also  seen  in  some  patients  whose  articular 
symptoms  may  originate  in  this  way,  without  the  gastric 
Drodroma. 

The  chief  clinical  forms  of  gouty  stomach  affections 
are  the  chronic  dyspeptic,  the  chronic  catarrhal,  the  gas- 
tralgic,  and  the  metastatic  variety. 

Gouty  dyspepsia,  a  chronic  and  inveterate  ailment,  is 
usually  coupled  with  a  peculiar  intolerance  for  certain 
articles  of  diet.  There  is  commonly  much  acidity,  with 
or  without  acid  eructations,  and  flatulence.  It  is  apt  to 
coexist  with  the  gouty  state. 

Chronic  gastric  catarrh  is  also  a  complication  of  advanced 

*  Cf.  p.  257. 


GOUTY  AFFECTIONS  OF  THE  STOMACH  217 

gout,  and  is  aggravated  by  the  cachexia.  It  is  known  by 
the  characteristic  daily  or  periodic  vomitings  of  stringy 
mucus  or  of  clear  fluid. 

The  chronic  gastralgic  varieties,  as  pointed  out  by  Rendu, 
are  more  commonly  observed  in  inherited  goutiness,  long 
preceding  the  articular  attacks,  the  advent  of  which  may 
be  their  cure.  Remarkable  instances  of  the  rapid 
amendment  of  a  long-standing  painful  dyspepsia  on  the 
development  of  articular  gout  have  been  reported  by 
Ebstein,  Rendu,  and  others. 

It  may  happen  that  after  the  cessation  of  a  long-estab- 
lished recurrence  of  gouty  attacks  gastralgic  dyspepsia 
may  supervene.  Treatment  appropriate  to  the  gout  will 
usually  be  followed  by  improvement. 

Gotity  metastatic  gastritis  belongs  to  the  most  severe 
clinical  type  of  gouty  retrocedence.  Whether  this  name 
is  accurately  descriptive  is  an  open  question,  little  being 
known  concerning  the  anatomical  changes.*  The  fre- 
quency of  this  affection  is  less  than  reported  by  former 
observers,  and  there  is  much  probability  in  Duckworth's 
suggestion  that  before  Heberden's  time  a  proportion  of 
the  fatal  cases  must  have  been  instances  of  angina  pectoris. 

Gouty  G astro-intestinal  ■  Affections. — The  intense  irrita- 
bility or  intolerance  of  the  goutily  affected  membranes  to 
relatively  slight  irritation  is  nowhere  better  exemplified 
than  in  the  gastro-intestinal  tract.  Vomiting,  gastralgia, 
colic,  and  diarrhoea,  sometimes  violent  and  accompanied 
with  depression,  are  apt  to  occur  on  relatively  trifling 
provocation.  Here,  again,  as  in  bronchitis,  the  relief 
afforded  to  the  disturbed  membrane  by  some  gouty  out- 

*  Duckworth  {/oc.  «/.,  p.  89),  however,  gives  a  case  in  which  some 
pathological  change  was  found,  and  refers  to  another  recorded  by 
Moxon  ('Transactions  of  the  Pathological  Society,'  1870),  which  pre- 
sented intense  congestion,  submucous  haemorrhages,  and  adherent 
pellicles  of  lymph. 


2i8         GOUTY  GASTRO-INTESTINAL  AFFECTIONS 

break  elsewhere  is  almost  conclusive  evidence  of  a  strongly- 
gouty  element  in  the  symptoms  described. 

The  prevalence  of  dyspepsia  and  irritable  bowels  is  so 
great  also  among  those  who  present  very  different  clinical 
family  histories  and  constitutions,  that  it  is  difficult  to 
demonstrate  the  gouty  nature  of  the  more  chronic  and 
trivial  forms  of  gastric  or  intestinal  disturbance  in  the 
individual  case  unless  light  should  be  thrown  upon  it  by 
a  gouty  record,  or  by  the  local  vestiges  of  past  attacks. 

In  the  metastatic  variety  all  doubt  of  this  kind  is 
practically  removed,  so  sudden  and  striking  is  the  trans- 
ference of  suffering  from  the  joints  to  the  mucous  mem- 
brane. The  question  whether  the  metastasis  is  a  purely 
nervous  phenomenon,  or  may  assume  the  proportions  of  a 
definite  lesion,  is  one  difficulty  to  set  at  rest,  although 
in  favour  of  the  latter  view  we  derive  strong  analogies 
from  the  visible  changes  in  the  pharyngeal  membrane,  and 
from  those  obtained  by  means  of  the  cystoscope,  as  well 
as  from  an  inspection  of  the  discharge  from  the  bladder 
in  gouty  cystitis. 

Gouty  Enteritis. — As  with  gouty  gastritis,  it  is  difficult, 
where  so  many  other  influences  may  be  at  work,  to  prove 
that  the  affection  in  a  given  case  is  specifically  gouty.  It 
may  be  well  to  define  at  once  clearly  the  varieties  which 
have  been  described.  Gastro-enteritis  may  be  set  up  by 
irritants  of  various  kinds,  and  the  occurrence  of  irritation 
is  specially  frequent  in  gout,  whether  owing  to  excess  or, 
as  in  inherited  delicacy,  to  undue  susceptibility.  Attacks 
due  to  indigestion  are  the  most  common.  A  small  group 
of  cases  of  enteritis,  more  strictly  so  called,  has  been  con- 
nected with  gout  itself  as  a  most  likely  cause,  and  Dr. 
Haig  has  advocated  the  use  of  salicylates  in  its  treatment. 
Sir  Dyce  Duckworth*  is  also  a  believer  in  the  existence 
*  Loc.  «■/.,  p.  291. 


GOUTY  ENTERITIS  219 


of  a  gouty  enteritis,  of  which  he  recognises  a  spasmodic 
and  a  catarrhal  form — the  first  apt  to  be  complicated  with 
constipation,  the  second  with  diarrhoea  and  vomiting. 
The  writer  has  witnessed  a  remarkable  case  of  the  second 
type  in  an  alcoholic  and  albuminuric  patient.  The 
severity  of  the  symptoms  was  alarming,  but  the  patient 
recovered;  and  two  mild  attacks  of  gout  in  the  toe 
occurred  at  intervals  of  a  few  days. 

The  fact  that  the  '  arthritic  colic  '  of  Musgrave,  which 
Sir  Dyce  Duckworth  regards  as  having  often  been  lead- 
colic  from  cider-drinking,  is  so  much  less  commonly  seen 
in  our  times,  finds  the  same  ready  explanation  as  the  re- 
duced frequency  of  gouty  gastritis.  The  organs  are  less 
tried  than  they  were  in  days  of  less  careful  living.  Above 
all,  abdominal  diagnosis  has  made  giant  strides.  To  say 
nothing  of  lead-colic  itself,  biliary  colic,  floating  kidney, 
appendicitis,  and  ovarian  affections  have  divided  between 
them  the  major  part  of  the  previous  domain  of  gouty 
gastro-enteritis. 

III. 

GOUTY  AFFECTIONS  OF  THE  URO-GENITAL  MUCOUS 
MEMBRANE  :  AND  OF  THE  ORGANS  OF  REPRO- 
DUCTION. 

Gouty  '  Irritable  Bladder.' — The  bladder  troubles  often 
diagnosed  as  gouty  are  probably  swelled  by  those  merely 
depending  upon  senility,  with  its  tendency  to  atony,  sedi- 
mentation, sacculation,  prostatic  enlargement,  retention, 
and  catarrh.  Any  of  these  might  conceivably  act  as  the 
exciting  cause  of  a  superadded  gouty  affection.  At  any 
rate,  the  condition  known  as  irritable  bladder  is  common 
in    the    gouty,    and,    as    suggested    by   Todd,*    bladder 

*  Of.  Todd,  '  Clinical  Lectures  on  certain  Diseases  of  the  Urinary- 
Organs,'  1857. 


GOUTY  URETHRITIS  AND  CYSTITIS 


affections  are  not  less  likely  to  occur  under  the  influence 
of  gout  than  bronchitis  or  gastritis. 

The  irritant  to  the  membrane  is  usually  the  urine  itself, 
through  its  excessive  acidity,  or  the  presence  within  it  of 
sharp  crystals  of  uric  acid  or  of  calcium  oxalate.  The 
urethritis  stated  to  occur  sometimes  towards  the  end  of  a 
gouty  arthritis  bears  the  same  interpretation. 

Gouty  Urethritis  and  Cystitis. — Here,  again,  we  cannot 
lose  sight  of  the  influence  of  age  as  affecting  the  question 
as  to  a  strictly  gouty  causation. 

That  the  bladder  is  liable  to  a  distinct  gouty  catarrh 
has  been  asserted  on  the  strength  of  instances  of  its 
metastatic  implication  in  the  course  of  an  arthritic  attack, 
or  on  the  abrupt  cessation  of  a  severe  gouty  eczema.  Sir 
Dyce  Duckworth*  describes  such  acute  symptoms  as 
sudden  onset  of  pain,  hsematuria,  ardor  urinae,  muco- 
purulent sediment  in  a  scanty,  high-coloured  urine,  often 
persistence  of  the  acute  stage  for  days,  and  of  the  chronic 
condition  for  weeks.  He  also  points  to  the  occasional 
concomitant  or  immediately  ensuing  affection  of  the 
heart,  or  some  other  organ,  before  the  gout  may  return  to 
the  joints,  as  a  proof  of  the  gouty  nature  of  the  cystitis. 

Urethritis  may  also  be  metastatic,  according  to  the 
same  authority,  and  accompanied  with  puriform  discharge 
and  scalding,  such  as  to  cast  doubt  at  iirst  on  the  diag- 
nosis. 

Spontaneous  hcemorrhage  from  the  bladder,  independently 
of  gravel  or  stone,  was  regarded  by  Todd  as  capable  of  a 
gouty  origin. 

Gouty  Orchitis. — This  is  recognised  by  some  surgeons  of 
experience  as  a  distinct  affection  traceable  to  gout,  and 
amenable  to  its  treatment.  My  colleague,  Mr.  Bennett, 
informs  me  that  he  has  seen  it  repeatedly.    It  is  associated 

*  Loc.  cit.,  p.  294. 


OVARIAN  AND  UTERINE  GOUT  221 

with  effusion  into  the  tunica  vaginahs,  and  impHcates  the 
entire  organ.  Debout  d'Estrees"^  has  observed  its  occur- 
rence without  effusion.  Parotitis,  according  to  Duck- 
worth, though  it  may  occur  from  gout,  has  not  been  re- 
corded in  connection  with  gouty  orchitis. 

The  Ovary  and  the  Uterus  in  Relation  to  Gout. — Looking 
at  the  hereditary  feature  of  gout,  we  might  regard  its 
incidence  on  the  ovary  as  not  improbable.  The  exist- 
ence of  ovarian  gout  was  formerly  recognised,  but  is  not 
now  believed  in  by  the  majority  of  gynaecologists,  and 
would  be  difficult  to  prove,  though  a  gouty  origin  would 
not  be  easily  excluded  in  cases  of  unexplained  ovaritis 
occurring  in  gouty  subjects  at  the  gouty  age."f- 

Again,  the  apparent  probability  of  a  liability  of  the 
uterus  to  gout  is  obvious.  The  immunity  of  so  important 
a  mucous  membrane  as  the  uterine,  and  of  one  reacting  in 
so  marked  a  degree  to  constitutional  states,  and  fulfilling, 
moreover,  an  emunctory  function  in  relation  to  the  blood, 
would  be  matter  for  surprise  in  contrast  with  the  liability 
of  all  other  mucous  membranes,  but  for  its  relative  free- 
dom from  exposure  to  irritation.  Uterine  gout  was 
formerly  much  dwelt  upon. 

A  gouty  uterine  catarrh  was  recognised  by  Storck  and 
Stoll,  and  much  more  recently  by  Sir  Spencer  Wellsj  and 
by  N.  Gueneau  de  Mussy.  The  latter  traced  in  some 
cases    an    alternation    between   the   uterine    catarrh    and 

*  Quoted  by  Duckworth  {loc.  cit.,  p.  113). 

t  Duckworth  {loc.  cit.,  p.  277)  quotes  Sir  W.  Priestley's  opinion, 
that  '  women  of  gouty  heritage  are  more  apt  than  others  to  suffer 
from  chronic  metritis,  chronic  capsular  and  interstitial  ovaritis,  and 
menorrhagia.' 

X  '  I  have  known  some  cases,  and  heard  of  many  others,  where  the 
females  of  the  family,  the  male  members  of  which  suffered  from 
ordinary  attacks  of  gout,  have  been  subject  to  a  kind  of  uterine 
catarrh,  the  uterine  discharge  being  very  thick  and  irritating,  or 
abundant  and  watery'  {loc.  cit.,  p.  166). 


UTERINE  GOUT 


bronchitis  and  eczema,  and  lays  weight  upon  the  circum- 
stance that  the  catarrh  is  often  accompanied  with  vulvar 
eczema  and  pruritus. 

Rendu,  who  discusses  these  possibilities  at  some  length, 
does  not  venture  to  assert  the  existence  of  a  distinct 
'  uterine  gout,'  but  is  a  firm  believer  in  a  constitutional 
element  at  the  root  of  some  forms  of  catarrh  and  of 
menorrhagia.  The  present  attitude  of  gynaecologists  is 
one  of  scepticism  as  to  the  alleged  connection. 


CHAPTER  XXV. 
THE   LIVER   AND   THE    KIDNEY   IN    GOUT. 

THE  GOUTY  AFFECTIONS  OF  THE  LIVER. 

Gouty  glycosuria  may  be  regarded  as  the  result  of 
hepatic  derangement,  and  a  long  chapter  might  be  devoted 
to  this  subject  alone ;  yet  this  is  but  one  form  of  the 
gouty  hepatic  disorders.  Next  to  the  frequency  of  minor 
disturbances  attributable,  or  at  any  rate  attributed,  to  the 
liver,  the  most  striking  fact  is  the  rarity,  nay,  the  absence, 
of  any  serious  organic  affection  traceable  to  the  disease. 
It  was  long  ago  pointed  out  by  Garrod  that  the  liver  is 
not  the  seat  of  any  uratic  deposits,  and  does  not  undergo 
structural  changes  differing  from  those  which  are  observed 
in  non-gouty  subjects. 

A  slight  hepatic  congestion  commonly  accompanies  the 
acute  gouty  attack ;  this  has  been  noted  by  most  ob- 
servers. Again,  recurring  or  habitual  functional  biliary 
irregularities  are  the  prominent  feature  in  the  clinical  his- 
tory of  some  sufferers  from  goutiness.  Neither  this  nor 
the  more  severe  forms  of  hepatic  disturbance  presently  to 
be  mentioned  lead,  however,  so  far  as  we  know,  to  any 
perceptible  organic  change. 

Secondary  hepatic  disturbances  in  gout  are  of  every-day 
occurrence.  The  most  frequent  and  least  dangerous  are 
transient  attacks  in  which  the  liver  is  rather  sinned 
against  than  sinning.     Many  of  these,  however,  are  truly 


224  THE  GOUTY  AFFECTIONS  OF  THE  LIVER 

gastric,  the  outcome  of  real  excess  in  the  case  of  the 
plethoric  and  non-dyspeptic  subjects,  or  of  relative  excess 
or  imprudence  in  those  of  weak  stomach,  or,  lastly,  of 
reflex  indigestion  in  the  high-strung  nervous  persons  in 
whom  goutiness  is  usually  inherited. 

*  Gout  in  the  Liver.' — A  much  more  serious  condition  is 
sometimes  observed.  The  liver  appears  to  bear  the  brunt 
of  the  gouty  process,  whilst  all  other  local  manifestations 
are  in  abeyance.  The  hepatic  functions  are  radically 
disordered ;  nutrition  suffers  severely,  and  the  patient's 
weakness,  emaciation,  muddy  pallor  or  subicteric  sallow- 
ness  and  cachectic  look,  may  be  such  as  to  create  serious 
alarm,  or  even  to  raise  a  suspicion  of  the  presence  of 
carcinoma.  The  symptoms  may  continue  unabated  for 
weeks,  when  under  appropriate  treatment  perfect  health 
may  be  restored. 

The  descriptive  name  '  gout  in  the  liver '  may  be  a 
pure  metaphor.  We  possess  no  strict  evidence  of  the 
gouty  nature  of  the  attack ;  it  may  be  merely  an  inter- 
current phenomenon  in  a  gouty  clinical  history.  Indeed, 
its  pathology  itself  is  obscure.  Most  probably  the  grave 
derangement  in  the  function  of  the  liver-cells  is  the  out- 
come of  a  subacute  and  pervading  catarrh  of  the  intra- 
hepatic biliary  system,  which  may  lead  to  a  sub-acute 
parenchymatous  hepatitis.  We  are  familiar  with  similar 
gouty  processes  in  the  respiratory,  the  genito-urinary,  as 
well  as  in  the  entire  length  of  the  alimentary  mucous 
tract.  The  implication  of  the  parenchyma  would,  accord- 
ing to  this  view,  own  a  simple  and  common  mechanism, 
and  would  derive  its  specially  serious  features  from  the 
structural  peculiarities  of  the  organ.  This  remarkable 
affection  is  met  with  in  the  subjects  of  irregular,  or  imper- 
fectly arthritic,  gout,  who  are  often  the  inheritors  of  a 
gouty  tendency,  and  perhaps  more  specially  in  women. 


THE  GOUTY  AFFECTIONS  OF  THE  LIVER  225 

Metastasis  to  the  Liver. — The  metastasis  of  acute  gout  to 
the  hver  has  not  been  dwelt  upon  by  modern  authorities. 
Putting  aside  bihary  coHc,  no  symptoms  probably  occur 
sufficiently  severe  to  excite  special  attention.  It  is  diffi- 
cult to  say  to  what  extent  the  liver  may  suffer  directly 
under  the  influence  of  the  acute  gouty  state.  Rendu 
believes  in  gouty  paroxysmal  congestions  of  the  organ, 
and  gives  the  case  of  a  lady  (the  subject  of  asthma)  who 
was  liable  to  severe  hepatic  crises,  apparently  congestive, 
with  considerable  increase  in  the  size  of  the  liver,  but 
without  any  vomiting  or  the  slightest  evidence  of  gall- 
stone. The  attacks  were  excited  by  indigestion,  by  the 
onset  ofthecatamenia,  and  particularly  by  moral  influences, 
and  were  liable  to  alternate  with  attacks  of  diarrhoea, 
which  brought  relief  rather  than  distress,  and  a  diminution 
in  the  hepatic  swelling. 

The  Biliary  System  and  Gall-stones  in  Gout.  —  The 
immunity  of  the  liver  in  gout  from  any  structural  lesions 
is  in  itself  an  important  and  suggestive  fact,  especially 
since  a  great  proportion  of  those  changes  which  occur  are 
connected  with  the  presence  of  biliary  sedimentation  or 
gall-stones.  The  relation  of  biliary  lithiasis  to  gout  has 
been  much  debated,  and  from  an  early  date.  Rendu, ^ 
who  mentions  the  observations  of  Hoffmann,  Morgagni, 
Portal,  and  others,  gives  the  evidence  collected  by  Senac 
of  Vichy,  who  found  that,  among  166  cases  of  biliary 
lithiasis,  95  had  gout  or  an  inherited  tendency  to  it. 
Bouchard  likewise  found  that  gout  in  the  parents  occurred 
in  30  per  cent.,  and  rheumatism  in  43  per  cent.,  of  the 
cases. 

Rendu  suggests   that    the   connection  with  gout    may 
have   often   been   overlooked   because   biliary   colic   is    a 
disease  of  the  younger  adult,  gout  coming  on  later  in  life, 
*  Loc.  cit.^  p,  144. 

15 


226  GOUTY  AFFECTIONS  OF  THE  KIDNEY 

when  gall-stones  tend  to  acquire  considerable  size  and 
to  excite  less  spasm.  Murchison  had  dwelt  upon  the  fre- 
quency of  jaundice  in  gout,  independently  of  biliary  colic, 
and  given  instances  of  the  occurrence,  under  the  influence 
of  heredity,  of  congestive  jaundice  in  connection  with  gout, 
in  several  members  of  the  same  family. 

GOUTY  AFFECTIONS  OF  THE  KIDNEY. 

There  are  few  clinical  facts  to  note  in  relation  to  the 
kidney ;  they  refer  mainly  to  the  varying  characters  of  the 
secretion,  including  temporary  or  permanent  albuminuria, 
which  have  been  elsewhere  described,  and  to  the  insidious 
progress  of  the  interstitial  changes. 

The  Gouty  Kidney. — With  the  exception  of  pain  arising 
from  renal  calculus  or  gravel,  renal  symptoms  do  not  usually 
excite  the  patient's  notice.  There  is  nothing  abrupt  in 
the  development  of  the  chronic  kidney  affection,  and 
acute  tubal  nephritis  is  exceptional.  The  first  indication 
of  renal  trouble  observed  by  the  patient  is  the  increased 
frequency  and  abundance  of  micturition ;  that  for  which 
the  physician  will  look  is  the  increased  tension  in  the 
arterial  system. 

The  severity  and  the  duration  of  the  chronic  affection 
vary  widely.  A  rapidly  fatal  course  is  the  exception. 
The  rule  is  rather  for  the  cases  to  progress  slowly  and 
last  long.  Intercurrent  affections,  and  especially  cerebral 
haemorrhage  or  pulmonary  congestion,  or  the  ultimate 
cardio-vascular  consequences  of  Bright's  disease,  close 
the  scene  more  commonly  than  acute  uraemia. 

Renal  Congestive  Gouty  Attacks. — The  kidney  might  have 
been  regarded  as  not  the  least  likely  among  organs  to 
suffer  from  acute  and  alternating  gouty  attacks  ;  but  of 
occurrences    of    this    kind    nothins;    definite    is    known. 


GOUTY  AFFECTIONS  OF  THE  KIDNEY  227 

Charcot,  however,  has  observed  the  signs  and  symptoms 
of  temporary  renal  congestion,  viz.,  deep-seated  lancinat- 
ing pains  in  the  loins,  slight  albuminuria,  and  even 
haematuria,  not  necessarily  bound  up  with  the  passage 
of  gravel,  and  therefore  capable  of  bearing  the  interpre- 
tation in  question.* 

Temporary  albuminuria  is  well  known  to  be  a  frequent, 
though  not  constant,  accompaniment  of  the  acute  attack, 
disappearing  entirely  with  its  cessation.  Lecorche  has 
found  its  occurrence  to  coincide  with  the  renewed  excre- 
tion of  the  uric  acid  on  the  third  or  fourth  day,  after 
which  it  soon  disappears,  as  the  amount  of  uric  acid 
excreted  lessens  again.  An  occasional  transient  albu- 
minuria, without  obvious  or  definite  provocation,  is  also 
observed  in  gouty  subjects  who  may  remain  permanently 
free  from  renal  disease.  This  is  probably  in  most  cases 
the  result  of  faulty  digestion  or  assimilation  or  of  undue 
acidity.  We  possess  no  evidence  in  support  of  the  view 
that  functional  or  cyclic  albuminuria  is  more  common  in 
gouty  subjects  than  in  others. 

Permanent  albuminuria  of  slight  degree  has  been  shown 
by  Garrod  to  be  a  frequent  occurrence  in  confirmed  gout. 
It  is  highly  suggestive  of  renal  disease.  Nevertheless,  the 
irritation  due  to  the  not  infrequent  co-existence  of  oxaluria 
should  not  be  forgotten  as  a  possible  explanation  in  some 
cases  of  recurring  albuminuria  and  haematuria. 

Ephemeral  glycosuria  may  accompany  the  acute  attack. 
The  frequent  association  of  glycosuria  with  chronic  gout 
need  not  be  insisted  on  at  this  place  ;  glycosuria  and 
diabetes  will  be  further  considered  under  the  heading  of 
Treatment. 

*  Cf.  Rendu,  loc.  «/.,  p.  127. 


CHAPTER  XXVI. 
THE  HEART  AND  BLOODVESSELS  IN  GOUT. 

THE  GOUTY  HEART  AFFECTIONS. 

The  '  Gouty  Heart.' — It  has  already  been  hinted  that  it 
is  difficult  to  separate  the  '  gouty  heart '  from  some  other 
forms  of  chronic  disease  as  a  specially  distinct  anatomical 
quantity,  although  lesions  of  the  coronary  arteries  and 
their  consequences  are  conspicuously  common  in  gout. 
On  the  other  hand,  the  term  is  clinically  appropriate  when 
applied  to  the  symptoms  and  aspects  of  the  functional 
cardiac  derangements  peculiar  to  gouty  subjects. 

Distinct  cardiac  features  belong  to  granular  kidney  dis- 
ease :  those  of  hypertrophy  of  the  left  ventricle,  such  as 
powerful  cardiac  impulse,  a  displaced  and  forcible  apex 
beat,  an  increased  area  of  dulness,  and  loudness  of  the 
first  sound,  etc. ;  and  those  of  peripheral  resistance  and 
high  blood-pressure,  viz.,  sustained  and  hard  pulse,  exag- 
gerated loudness  of  the  second  sound,  reduplication,  with 
loudness,  of  the  first  sound  at  the  apex,  and  ultimately  a 
thickened  and  rigid  condition  of  the  arterial  wall.  Subse- 
quent failure  and  dilatation  of  the  hypertrophied  heart, 
with  its  greatly  increased  dulness,  tumultuous  and  rapid 
action,  overcharged  pulmonary  and  venous  system,  are 
also  easily  identified. 

Again,  atheromatous  degeneration  of  the  coronary  arteries, 
and  the  resulting  fatty  degeneration  of  the  heart-wall,  pre- 


THE  GOUTY  HEART  AFFECTIONS  229 

sent  well-known  symptoms  and  signs.  None  of  these 
cardio-vascular  symptoms,  common  as  they  are  in  gout, 
are  exclusive  results  or  features  of  the  affection.  They 
should  not  be  included  under  the  term  '  gouty  heart '  in 
its  clinical  acceptation. 

When  these  major  complications  induced  by  kidney 
disease  in  inveterate  gout  have  been  deducted,  there  re- 
mains a  large  set  of  heart  symptoms  independent  of  coarse 
organic  lesion,  in  which  we  can  trace  the  operation  of  the 
special  factors  of  gout.  Dr.  Mitchell  Bruce  has  devoted 
to  their  description  a  valuable  article  in  the  Practitioner  ;* 
and  Dr.  Balfour  refers  to  them  in  his  recent  work.  The 
paroxysmal  character  of  these  changes,  coupled  with  their 
capacity  for  relief  by  appropriate  treatment,  shows  them 
to  be  mainly  functional.  The  minute  structural  changes 
which  may  underlie  them  do  not  admit  of  demonstration, 
any  more  than  those  due  to  gouty  malnutrition  in  the 
other  tissues. 

In  the  functional  peculiarities  of  the  gouty  heart  we 
recognise,  as  elsewhere,  irritability  and  diminished  resist- 
ance, especially  in  connection  with  innervation.  The 
gouty  heart  is  typically  a  nervous  heart. 

Irregularity  is  generally  the  first  degree  of  the  irritation 
and  excitability.  In  itself  this  is  not  a  gouty  symptom. 
The  irregular  and  intermittent  pulse  of  the  middle-aged  or 
elderly  subject  is  often,  strictly  speaking,  an  evidence  of 
his  gouty  dyspepsia.  The  arythmia  may  sometimes  be- 
come extreme,  and  may  be  accompanied  with  distressing 
sensations. 

Unnatural   rapidity  may   be   associated   with   the   con- 
sciousness  of  heart-hurry,  or  palpitation ;   or  it  may  be 
unconnected   with    any   subjective    feelings.      The   over- 
acting and  thumping  heart  is  generally  a  '  conscious '  one. 
*  Cf.  Practitioner,  January,  1895. 


230  THE  GOUTY  HEART  AFFECTIONS 

Bradycardia,  or  unnatural  slowing,  a  permanent  anomaly 
in  some  conditions,  is  often  in  gout  or  goutiness  of 
temporary  duration,  and  apt,  like  tachycardia,  to  occur 
on  the  sudden  retrocession  of  the  articular  symptoms. 
More  commonly  its  onset  is  unexplained,  and  should  then 
suggest  the  possible  influence  of  a  latent  gouty  state. 

Why  such  opposite  conditions  should  be  capable  of  this 
alleged  uniform  derivation  is  a  problem  as  obscure  as 
everything  relating  to  cardiac  neuroses.  Individual 
peculiarity  is  nowhere  more  striking  than  in  connection 
with  the  character  of  cardiac  action.  Quite  apart  from 
gout,  some  subjects  present  an  acceleration,  others  a 
slowing  of  the  heart's  rhythm  under  mental  excitement ; 
and  visceral  stimuli  probably  take  similar  effect.  Nay, 
the  same  heart  may  at  different  times  be  liable  to  hurry 
and  palpitation,  or  to  distressing  slowness  and  feebleness 
of  action. 

Painful  heart  affections  also  belong  to  the  group  of 
functional  disorders  of  the  gouty  heart.  Their  import- 
ance is  great  in  proportion  to  their  resemblance  with  true 
angina,  itself  a  too  frequent  result  of  gout,  to  the  difficulty 
of  a  safe  diagnosis,  to  the  opposite  indications  of  treat- 
ment, and  to  the  contrast  in  the  prognosis  of  the  two 
conditions.  In  its  fully-developed  form  the  painful  affec- 
tion has  received  the  name  of  pseudo-angina.  Its  outward 
symptomatic  identity  with  angina  is  sometimes  so  great 
that  we  may  question  the  propriety  of  the  qualification 
'  false' ;  at  any  rate,  in  respect  of  the  pain  and  of  the  cardiac 
distress.  The  chief  difference  lies  in  the  causation,  not  in 
the  symptoms.  The  same  agony  of  pain  and  of  suifoca- 
tion,  the  same  irradiation  down  the  arm,  the  same  feeling 
of  arrest  of  breath  and  circulation,  the  same  gastric  com- 
plications, may  be  present  in  both  ;  but  their  significance 
is  totally  different.     Perhaps  the  chief  distinction  between 


THE  GOUTY  HEART  AFFECTIONS  231 

the  more  severe  functional  seizures  and  the  fits  of  real 
angina  resides  in  the  patient's  innermost  feelings :  dread 
of  death  in  the  one  case,  consciousness  of  dying  in  the 
other.  The  age  of  the  patient  might  be  of  greater  diag- 
nostic value  were  it  not  that  the  period  for  confirmed 
gout  is  also  that  for  angina  ;  moreover,  the  immunity  from 
fatal  angina  is  not  absolute  even  in  early  adult  life,  though 
the  cases  observed  are  undoubtedly  rare. 

Well-authenticated  cases  are  on  record  in  which  grave 
attacks  supervened  immediately  after  the  retrocession  of 
articular  symptoms,  and  were  clearly  connected  with  gout. 
Fortunately,  the  type  of  the  functional  affection  is  not 
usually  pure,  and  most  cases  may  be  described  as  anginoid 
rather  than  anginal.  Not  only  may  we  miss  the  symptom 
of  meditatio  mortis,  but  there  may  be  comparatively  less 
of  faintness  than  of  cardiac  and  irradiated  pain,  whilst  the 
flatulency  and  gastric  disturbance  may  be  more  prominent 
features.  Again,  in  the  history  of  the  attack  indigestion 
often  plays  a  more  conspicuous  part  than  is  usual  in 
Heberden's  disease. 

The  Minor  Cardio-vascular  Symptoms  of  Goutiness. — Any 
of  the  symptoms  described  may  occur  in  immediate  and 
alternating  relation  with  articular  seizures,  or  they  may 
appear  on  the  scene  quite  independently,  even  in  those 
who  merely  inherit  a  tendency  to  gout.  A  practical 
acquaintance  with  instances  of  the  same  direct  association 
explains  the  view"^  taken  by  former  physicians,  that  most 
of  the  cardio-vascular  neuroses  which  are  so  common  in 
young  females  were  gouty  manifestations.  One  of  the 
most  striking  among  them — Graves's  disease — may  un- 
doubtedly sometimes  occur  in  gouty  families.  Much 
more  often  no  such  connection  can  be  traced.  The  same 
remark  applies  to  the  pseudo-anginal  seizures  of  young 

*  C/.  ip.  22. 


232  THE  GOUTY  AFFECTIONS  OF  VEINS 

women,  and  to  various  other  neurotic  conditions,  which, 
for  want  of  some  better  explanation,  are  usually  classed  as 
hysterical. 

The  frequency  with  which  various  minor  derangements 
of  the  cardio-vascular  functions  occur  in  goutiness  leaves 
us  in  little  doubt  as  to  their  being  related  to  the  latter. 
Localized  excessive  arterial  pulsations,  peripheral  ischsemiae 
and  hypersemise,  permanent  dilatations  of  peripheral 
vascular  districts — as  seen  in  the  red  line  at  the  root  of 
the  nails — angio-neurotic  oedema  and  urticarial  rashes 
have  all  been  described  in  this  connection. 

The  articular  affection  itself  has  been  referred  by  some 
to  a  paroxysmal  venous  dilatation,  and  by  Owen  Rees  to  a 
'dilatation  of  the  capillaries.' 

THE  GOUTY  AFFECTIONS  OF  VEINS. 

Phlebitis*  more  painful  in  some  cases  than  in  others,  is 
always  an  important  affection  needing  patience  on  the  part 
of  the  sufferer  and  prudence  in  the  physician.  Gouty 
phlebitis  differs  from  some  other  forms  in  the  more  abiding 
character  of  its  cause  and  in  its  marked  tendency  to  recur- 
rence, which  necessitates  the  avoidance  of  all  circumstances 
likely  to  produce  a  relapse.  The  dangers  of  any  mechanical 
disturbance  of  the  limb — the  lower  extremity  is  much  more 
frequently  affected  than  the  upper — and  of  any  general 
vascular  excitement,  are  particularly  to  be  thought  of  during 
the  stage  of  softening  of  the  clot,  when  its  more  friable 
portions  are  liable  to  be  washed  into  the  venous  current  in 
sufficient  quantity  to  lead  to  pulmonary  embolic  throm- 
bosis.    It  is  not  impossible  that  some  of  the  minute  debris 

*  Cf.  Sir  James  Paget,  'St.  Bartholomew's  Hospital  Reports,' vol.  iii., 
1886;  Sir  Prescott  Hewett,  'Clin.  Soc.  Trans.,'  vol.  vi.,  1863; 
Dr.  Tuckwell,  'St.  Bartholomew's  Hospital  Reports,'  vol.  x.,  1874, 
quoted  by  Duckworth,  loc.  cit.,  p.  309. 


THE  GOUTY  AFFECTIONS  OF  VEINS  233 


may  gain  gradual  access  to  the  circulation,  without  any- 
worse  results  than  an  occasional  rigor  with  temporary 
elevation  of  temperature.  Some  cases  of  phlebitis  are 
specially  inveterate.  The  migratory  oedema  affecting  in 
succession  one  limb  after  another,  and  the  lungs  them- 
selves, is  not  commonly  seen  in  gout.  On  the  other  hand, 
a  recurrence  in  the  same  limb  is  frequently  observed.  Per- 
sistence of  oedema  for  long  periods  is  another  charac- 
teristic of  gouty  phlebitis  ;  but  individual  cases  vary  much 
in  this  respect. 

Men,  being  more  liable  to  gout,  are  also  more  often  the 
sufferers  from  this  form  of  phlebitis. 

Phlegmasia  Alba  Dolens. — This  distressing  affection  may 
be  regarded  as  an  ordinary  phlebitis  on  a  large  scale, 
involving  specially  the  deeper  veins,  and  leading  to  an 
unusually  firm  oedema  with  much  tenderness  and  pain ; 
there  is  still  much  mystery  connected  with  its  pathology. 
Whether  primarily — and  this  would  seem  extremely  prob- 
able— or  as  a  result  of  the  great  pressure,  the  lymphatics  of 
the  parts  are  disabled  and  absorption  almost  completely 
suspended  ;  hence  the  long  duration  of  such  cases. 

Phlegmasia  dolens,  so  prominently  connected  with  the 
puerperal  states,  is  also  an  affection  of  the  male,  and  par- 
ticularly of  the  gouty  male.  Striking  cases,  observed  by 
Dr.  Edward  Liveing,  are  given  by  Sir  Dyce  Duckworth 
{loc.  cit.,  p.  310).  A  hereditary  tendency  independent  of 
gout  is  a  well  known  peculiarity  of  this  disease.  Sir  C. 
Locock's  instance  of  four  daughters  suffering  from  phleg- 
masia, whose  father  also  had  phlebitis,  is  often  quoted. 
But  there  is  probably  a  special  tendency  to  this  transmis- 
sion when  gout  is  the  pathological  heritage. 

Gouty  phlebitis  is  specially  selected  by  Sir  James  Paget* 
as  a  support  for  the  view  that  new  developments  are  being 
*  '  Clinical  Lectures  and  Essays.' 


234  THE  GOUTY  AFFECTIONS  OF  VEINS 

evolved  in  our  diseases.  So  disabling,  disfiguring,  and 
tediously  prolonged  an  affection  as  phlebitis  could  not  have 
escaped  notice,  and  if  noticed  could  not  have  been  ignored 
by  our  predecessors ;  the  absence  of  records  relating  to 
it  would  suggest  that  it  was  not,  at  any  rate,  of  common 
occurrence. 

The  well-known  frequency  of  gouty  phlebitis  enables  a 
diagnosis  of  gout  to  be  often  made  where  an  otherwise 
unexplained  phlebitis  suddenly  develops  in  an  elderly 
patient. 

The  question  as  to  the  possible  connection  between  the 
acute  lesions  of  gout  and  a  local  '  capillary  phlebitis  ' 
(Owen  Rees)  is  discussed  elsewhere. 

Hcemorrhoids  are  an  occasional  trouble  with  gouty 
patients,  and  sometimes  need  very  judicious  management. 
Nothing  leads  us  to  suspect  that  any  gouty  peculiarity 
attaches  to  this  form  of  complaint,  nor  to  its  mode  of 
causation ;  and  its  treatment  should  be  carried  out  on 
generally  approved  principles. 

Varicose  veins,  the  production  of  which  is  so  largely 
influenced  by  the  state  of  the  portal  circulation,  and  so 
directly  favoured  by  a  plethora  of  fluids,  are  apt  to  be 
observed  in  the  gouty,  particularly  in  the  florid  subjects  of 
full  habit,  and  in  those  with  a  tendency  to  obesity  and 
relative  cardiac  inadequacy.  Its  occurrence  in  those  whose 
gout  is  brought  about  by  beer  is  well  known  to  every  prac- 
titioner, and  is  very  largely  seen  among  the  poorer  class  of 
gouty  subjects  in  London. 


CHAPTER  XXVII. 

THE  CUTANEOUS  SYSTEM  AND  THE  ORGANS 
OF  SPECIAL  SENSE. 

THE  SKIN  IN  GOUT  AND  IN  GOUTINESS. 

The  intimate  coimection  of  the  skin  with  the  nervous 
system,  which  is  so  largely  impHcated  in  gout,  adds  much 
importance  to  its  clinical  study.  Due  regard  to  this 
association  is  of  the  greatest  practical  use  in  the  diagnosis 
and  in  the  treatment  of  gout,  as  well  as  of  cutaneous 
ailments.  And,  again,  it  warrants  us  in  attributing  to  the 
skin,  as  a  department  of  the  nervous  system,  some  share 
in  determining  a  liability  to  gout,  though  the  much  larger 
share  belongs  to  the  latter.  Those  conditions  which  tend 
to  render  the  skin  delicate  and  susceptible  contribute  also 
to  establish  the  liability,  whilst  in  gout  itself  the  cutaneous 
dehcacy  is  largely  responsible,  as  a  determining  cause  for 
the  onset  of  various  complications,  more  particularly  of 
the  catarrhs. 

That  the  majority  of  the  subjects  of  acquired  gout 
should  possess  a  smooth  and  delicate  skin  may  be  simply 
due  to  the  greater  frequency  of  gout  among  the  non- 
labouring  classes.  Gout  is  not  restricted  to  any  one  type 
of  constitution  or  of  skin  ;  and  with  special  regard  to 
articular  gout,  it  would  be  impossible  to  establish  a  parallel 
between  pecuHarities  of  the  skin  and  of  the  joints,  although 


236  THE  SKIN  IN  GOUT  AND  IN  GOUTINESS 

the  delicacy  of  the  skin  may  often  be  taken  as  a  gauge  of 
the  vulnerabihty  of  the  system  at  large.  More  perhaps 
than  any  other  tissue  the  skin  tells  us  of  the  constitution. 
In  the  vulnerability  often  coinciding  with  a  thin  skin  the 
lymphatic  system  and  the  nervous  system  are  closely  con- 
cerned. It  might  be  said  that  the  lymphatic  delicacy  was 
more  prominent  in  the  scrofulous  subjects,  the  nervous 
more  so  in  the  gouty.  In  the  latter  we  find  the  great 
neuro-vascular  reactions — the  nerve  storms — not  cerebral 
only,  as  in  asthenic  gout  with  irritability,  but  sympathetic, 
leading  to  some  of  the  irregularities  of  gout,  and  neuralgic, 
particularly  in  the  asthenic  cases  subject  to  gouty 
neuralgia.  The  gouty  skin  affections  are  also  largely 
under  the  influence  of  the  nervous  system. 

Whilst  it  is  difficult  to  say  how  far  a  delicate  skin  may 
influence  the  liability  to  gout,  as  to  the  influence  of  gout 
in  promoting  cutaneous  delicacy  there  is  not  any  doubt. 
The  longer  gout  lasts,  the  more  marked  is  this  result,  and 
it  is  apt  to  be  most  marked  in  the  offspring,  who  frequently 
suffer  early  from  psoriasis,  eczema,  urticaria,  or  other 
affections,  and  in  this  way  display  almost  from  infancy 
their  constitutional  bias. 

The  peculiarities  of  the  skin  and  cutaneous  appendages 
commonly  observed  in  the  subjects  of  acquired  and  of 
inherited  gout  need  not  be  described  at  length.  Smooth- 
ness and  softness  of  skin  are  most  marked  in  the 
subjects  of  tophaceous  and  of  crippling  gout,  together 
with  some  atrophy,  but  they  are  not  limited  to  these 
types.  The  opposite  condition  of  harshness  and  of  dry- 
ness belongs  to  other  cases,  but  particularly  to  a  large 
group  of  those  who  inherit  goutiness,  and  of  the  sufferers 
from  psoriasis  derived  from  gouty  inheritance. 

The  skin  of  the  average  gouty  subject  acts  freely  under 
stimulation,  and  often  suffers  as  a  result  of  the  excess  and 


THE  SKIN  IN  GOUT  AND  IN  GOUTINESS  237 

irritating  quality  of  the  perspiration.*  During  intervals  of 
rest  it  is  less  active  and  drier  than  in  non-gouty  subjects. 

Sir  A.  Garrodf  derived  the  conclusion  from  an  analysis 
of  the  perspiration  obtained  at  a  Turkish  bath  from  a 
patient  with  inveterate  gout,  that  the  healthy  skin  is  not 
capable  of  eliminating  tiric  acid,  even  when  in  excess  in 
the  blood.  Urea  and  oxalate  of  lime  were  found  in  the 
secretion,  but  no  trace  of  uric  acid.  He  also  refers  to 
other  observations,  and  to  Charcot's  statement  that  in 
uraemia,  as  in  cholera,  urea,  but  no  uric  acid,  can  be  traced 
in  the  powdery  deposit  sometimes  found  at  the  surface  of 
the  skin.  These  observations  cast  considerable  doubt  on 
earlier  statements  as  to  the  occurrence  of  uric  acid  as  an 
excretion  from  the  skin.  Some  of  these  relate  to  the 
contents  of  the  serum  from  gouty  eczema.  Golding  Bird 
(1856)  believed  that  he  had  found  urate  of  soda  in  the 
secretion  from  a  case  of  this  kind.  Gigot  SuardJ  dis- 
covered urates  in  the  vesicles  of  eczema  and  of  pemphigus 
in  a  gouty  subject.  The  same  observer  has  attempted  to 
give  an  experimental  proof  of  the  local  influence  of 
uricacidaemia  upon  the  skin  by  the  ingestion  of  uric  acid. 
In  the  case  of  a  young  girl,  after  fifteen  daily  doses  of 
10  centigrammes  of  uric  acid,  he  observed  a  few  pustules 
of  ecthyma  on  the  hands  and  face. 

Rendu  draws  attention  to  the  occurrence  of  acne,  boils, 
and  carbuncles  as  an  antecedent,  as  an  alternation,  or  as  a 
sequel  of  the  gouty  attack,  in  connection  with  the  possi- 
bility of  a  local  determination  of  uric  acid  to  the  skin. 

The  nails  become  sooner  or  later  characteristic  in  their 
thinness  and  brittleness,  and  in  the  longitudinal  striation 

*  The  presence  of  urates  in  the  sweat,  although  denied  by  Garrod  and 
by  Duckworth,  is  asserted  by  Drs.  Meldon  and  Tichborne  {Brz't  Med. 
Journ.,  November  19,  1887,  p.  1097,  quoted  by  Duckworth),  who  give 
a  method  for  their  recognition. 

t  Loc.  cit.,  p.  118.  X  Quoted  by  Rendu,  loc.  cit.,  p.  136. 


238  THE  SKIN  IN  GOUT  AND  IN  GOUTINESS 

which  they  almost  invariably  present.  Sometimes  trans- 
verse striation  and  pitting  are  observed. 

The  teeth  have  been  described  as  strong  and  enduring 
in  those  who  develop  gout,  less  so  in  the  heirs  to  it. 

An  abundant  growth  of  hair  in  early  life,  with  early 
onset  of  baldness,  is  mentioned  among  the  peculiarities 
connected  with  a  gouty  constitution.  Early  grayness  has 
also  been  regarded  as  common  in  those  inclined  to  gout. 
What  foundation  may  exist  for  this  belief  appears  doubt- 
ful, having  regard  to  the  frequent  persistence  of  a  full 
supply  of  hair  throughout  a  long  life  of  recurring  gouty 
attacks.  Probably,  as  in  the  case  of  early  decay  of  the 
teeth,  some  constitutional  delicacy  or  circumstance  not 
connected  with  gout  is  the  determining  agent. 


THE  U RATIO  CUTANEOUS  AFFECTIONS. 

The  liability  of  the  skin  to  gouty  influence  is  proved  to 
demonstration  by  occurrence  of  deposits  within  it.  The 
subcutaneous  tophi  and  uratic  infiltrations  need  not  be 
again  described  (c/.  p.  121). 

On  the  strength  of  this  obvious  fact,  some  observers 
have  endeavoured  to  prove  the  uratic  nature  of  cutaneous 
inflammations  occurring  in  gout,  and  particularly  of 
eczema. 

THE  'GOUTY'  SKIN  AFFECTIONS. 

Although  the  attempt  to  trace  uric  acid  in  eczema  has 
failed,  the  close  connection  of  this  and  of  other  skin 
affections  with  gout  is  established  by  the  clinical  tests  set 
forth  in  connection  with  visceral  gout,  and  with  a  definite- 
ness  not  attainable  in  the  case  of  inflammation  of  deep- 
seated  membranes.  Alternation  with  the  arthritic  attacks 
is  a  very  marked  feature,  and  alternation  in  inheritance 


THE  'GOUTY'  SKIN  AFFECTIONS  239 

is  often  observed.  A  knowledge  of  this  fact  often  enables 
the  physician  to  diagnose  goutiness  before  it  has  found 
any  further  expression.  Bazin  founded  upon  it  his  well- 
known  group  of  '  arthritic  '  affections  of  the  skin,  and 
French  dermatologists  still  insist  upon  the  '  herpetic ' 
character  in  a  large  number  of  instances  where  a  gouty 
condition  can  hardly  be  traced.  This  undue  extension 
of  the  connection  does  not,  however,  invalidate  the  facts 
originally  pointed  out. 

Rendu  does  not  believe  in  any  distinctive  peculiarities 
in  the  appearances  of  gouty  cutaneous  eruptions,  as  com- 
pared with  other  forms.  Neither  their  polymorphous 
character,  their  circumscribed  distribution,  nor  their  occa- 
sional asymmetry  are  to  be  regarded  as  diagnostic.  He 
is  also  sceptical  as  to  the  diagnostic  value  of  the  sensa- 
tions of  prickling,  hyperaesthesia  and  hyperalgesia,  upon 
which  Bazin  formerly  laid  stress. 

Eczema. — No  other  disease  of  the  skin  can  compare 
with  eczema  in  respect  of  the  frequency  and  the  closeness 
of  its  association  with  gout.  According  to  Garrod,  no 
fewer  than  30  per  cent,  of  cases  of  inveterate  gout  would 
suffer.  Eczema  might  almost  be  regarded  as  the  cutaneous 
form  of  gout,  so  intimate  is  its  relation  with  the  disease. 
Not  only  is  it  capable  of  alternating,  in  hereditary  trans- 
mission, with  arthritic  gout  and  with  gouty  neuralgia  (a 
remarkable  instance  of  this  alternation  was  related  to  me 
by  Dr.  Bowles,  in  which  the  grandfather  had  severe  gout, 
the  son  severe  eczema,  and  the  grandson  tic  douloureux) ; 
but  it  may  at  times  in  the  individual  take  the  place  of  the 
arthritic  seizure,  or  precede  for  an  interval  of  years  the 
onset  of  the  arthritic  period.  Indeed,  in  some  instances 
the  arthritic  period  may  never  be  reached,  and  eczema 
then  becomes  in  the  clinical  history  an  isolated  manifesta- 
tion of  gout.     More  commonly,  however,  its  later  visita- 


240  THE  'GOUTY'  SKIN  AFFECTIONS 

tions  may  even  be  delayed,  as  pointed  out  by  Garrod,  till 
advancing  age  has  considerably  reduced  the  liability  to 
the  arthritic  ills.  It  presents  every  degree,  its  severity 
varying  with  the  constitutional  state  at  the  time,  and 
being  largely  determined  by  any  personal  predisposition 
to  cutaneous  troubles.  Its  acute  form,  especially  dis- 
tressing when  combined  with  urticaria,  and  its  chronic  dry 
form,  are  both  rebellious  to  local  measures,  and  sometimes 
difficult  to  cure  even  by  constitutional  remedies.  The 
aifection  is,  like  gout  itself,  prone  to  occur  in  spring  and 
autumn,  but  particularly  in  spring.  Symmetry  is  a  well- 
marked  feature  of  gouty  eczema,  which  also  presents  other 
peculiarities. 

Pityriasis  rubra  or  exfoliative  dermatitis  may  alternate 
with  gout.  According  to  Sir  Dyce  Duckworth,  a  gouty 
bias  would  be  present  in  one-fifth  of  the  cases.  This 
relation  is  not  to  be  wondered  at  in  connection  with  the 
similarity  which  the  disease  presents  with  eczema. 

Psoriasis  is  not  a  distinctly  gouty  ailment,  the  tendency 
to  thickening  of  the  epithelium,  except  under  constantly 
renewed  mechanical  pressure,  not  belonging  to  the  affec- 
tion. Garrod  traces  a  connection  rather  with  chronic 
rheumatic  than  with  gouty  arthritis.  Nevertheless,  since 
gout  attacks  every  constitution,  psoriasis  will  coincide 
with  it  sometimes.  This  association  will  call  for  due 
regard  in  connection  with  the  treatment. 

Acne,  boils,  and  carbuncles  are  all  occasionally  seen  in 
the  gouty.  The  severer  affection  is  a  relatively  late  mani- 
festation, to  which  patients  are  exposed  by  constitutional 
states  of  depression,  whilst  acne  and  boils  tend  to  be 
early  incidents  in  clinical  histories  which  may  subse- 
quently add  arthritic  gout  to  their  record. 

Pruritus  and  prurigo,  not  infrequently  associated  with 
and  intensifying  each  other,  are  affections  often  observed 


THE  'GOUTY'  SKIN  AFFECTIONS  241 

in  the  gouty  state  and  in  gouty  diabetes.  The  acid  state 
which  favours  the  gouty  trouble  aggravates  the  itching, 
which,  however,  may  possess  a  distinct  local  cause,  as  in 
the  vulvar,  anal,  and  preputial  forms. 

Urticaria  is  another  instance  of  the  reaction  of  the  skin 
to  the  influences  which  promote  the  arthritic  form  of 
gout.  The  frequency  of  nettle-rash  in  many  who  are 
not  gouty  should  be  remembered  by  the  side  of  those 
instances  where  the  same  mechanism,  viz.,  some  error  of 
diet,  may  provoke  either  the  arthritic  or  the  cutaneous 
gouty  response.  This  circumstance  throws  into  strong 
relief  the  existence  of  the  nerve  factor  in  gout.  As  to 
the  nature  of  the  irritant,  any  definite  statement  would 
be  premature ;  but  it  is  reasonable  to  assume  that  this 
would  be  the  same  in  gout  as  in  the  ordinary  cases. 

Angio-netcrotic  cedema  is  probably  related  to  urticaria. 
This  rare  affection  may  occur  in  gout.  Graves  described 
a  case  under  the  name  of  fugitive  gouty  inflammation. 

Herpes,  a  frequent  associate  of  gout,  may  precede, 
accompany,  or  follow  the  attack.  Sir  Dyce  Duckworth 
calls  attention  to  the  occasional  recurrence  of  herpes  at 
the  site  of  previous  injuries  in  a  retrocedent  form,  cutting 
short  an  arthritic  attack.  Severe  gouty  neuralgia  may  be 
complicated  with  shingles,  though  the  association  is  by 
some  regarded  as  more  frequently  rheumatic. 

Suhcidaneous  Nodules. — Analogous  symptoms  to  those 
now  commonly  recognised  as  rheumatic  have  also  been 
observed  by  Sir  Dyce  Duckworth  in  two  female  cases  of 
chronic  gout  and  of  saturnine  gout  respectively. 

Xerodermia  is  probably,  in  some  cases,  a  cutaneous 
degeneracy  induced  as  a  result  of  a  distant  gouty  inheri- 
tance. 

^stus  volaticus,  xanthoma,  and  perforating  idcer,  are  also 
mentioned   by    Duckworth   as    occasionally   observed    in 

16 


242    AFFECTIONS  OF  THE  ORGANS  OF  SPECIAL  SENSE 

gouty  subjects.  Painful  and  inflamed  corns  have  some- 
times been  mistaken  for  gouty  inflammation.  The  view 
that  gouty  subjects  are  specially  prone  to  this  troublesome 
ailment  is  not  established  on  sufficient  evidence. 


THE  GOUTY  AFFECTIONS  OF  THE  ORGANS  OF 
SPECIAL  SENSE. 

From  a  practical  standpoint  these  affections  appeal 
exclusively  to  specialists.  They  are  mentioned  here  in 
connection  merely  with  their  clinical  and  pathological 
interest. 

The  Eye. — The  obviousness  and  accessibility  to  examina- 
tion of  the  changes  in  the  eye  lend  to  their  study  con- 
siderable importance  from  the  point  of  view  of  the  clinical 
history  of  gout  and  of  its  diagnosis.  This  is  specially  true 
of  the  superficial  changes  implicating  the  conjunctiva  and 
the  palpebral  margin.  In  both  these  situations  we  re- 
cognise at  first  sight  the  distinctive  irritability  of  gouty 
mucous  membranes.  The  use  of  the  terms  gotcty  con- 
junctivitis and  gouty  blepharitis  may  be  considered  justified 
by  the  facts  observed. 

Situated  more  deeply,  but  still  within  easy  range  of 
observation,  may  be  recognised  the  changes  due  to  gouty 
episcleritis,  sclerotitis,  and  iritis.  The  symptoms  of  these 
affections  are  familiar.  We  note  that  they  are  often 
attributed  also  to  rheumatism. 

The  remaining  changes  are  matters  for  deeper  investiga- 
tion. They  include  glaucoma,  hcemorrhagic  retinitis,*  and 
choroiditis. 

Brudenell  Carter  is  of  opinion  that  much  so-called  gouty 
or  rheumatic  ophthalmia  is  glaucoma  occurring  in  a  sub- 
acute or  remittent  form. 

*  Described  by  Hutchinson,  '  Clin.  Soc.  Trans.,'  vol.  ix.,  p.  132,  1878. 


AFFECTIONS  OF  THE  ORGANS  OF  SPECIAL  SENSE     243 

The  whole  subject  of  the  gouty  affections  of  the  eye  has 
received  much  attention  from  Mr.  Jonathan  Hutchinson.* 

The  Ear. — The  occurrence  of  tophi  in  the  auricle  does 
not  require  any  further  notice.  Affections  of  the  external 
auditory  meatus,  especially  eczema,  are  sometimes  refer- 
able to  gout.  Garrod,  who  has  taken  notice  of  these 
lesions,  and  of  the  thickening  of  the  tympanic  membrane 
which  may  be  thereby  induced,  has  failed  to  trace  any 
uratic  deposits  in  the  tympanum,  or  in  connection  with 
the  joints  between  the  ossicles  or  with  their  ligaments. 
No  further  information  has  been  forthcoming  on  this 
subject. 

Deafness  may  be  sometimes  due  to  a  gouty  influence, 
when  not  otherwise  to  be  accounted  for.  This  perhaps 
might  explain  a  proportion  of  the  instances  of  so-called 
nerve  deafness ;  on  this  point  no  definite  evidence  is 
available.  Rendu  describes  the  onset  of  deafness  in  gout 
as  more  or  less  characteristic,  insidious,  slow,  and  pro- 
gressive, and  unaccompanied  with  pain  or  tinnitus. 

Auditory  vertigo  is  regarded  as  rare  in  gout,  most  in- 
stances of  giddiness  occurring  during  gouty  attacks  being 
connected  with  the  stomach  rather  than  with  the  labyrinth. 

*  'A  Report  of  the  Forms  of  Eye  Disease  in  Connection  with  Rheu- 
matism and  Gout.' — ■'  Ophthalmic  Hospital  Reports,'  1873,  and  various 
other  publications. 


CHAPTER  XXVIII. 

THE  NERVOUS  SYSTEM  IN  GOUT. 

Deeply  as  the  nervous  system  is  implicated  in  the  gouty 
manifestations,  we  are  ignorant  of  its  pathological,  and 
know  little  of  its  clinical,  aspects  in  connection  with  gout. 
Gouty  lesions  have  not  been  found  in  the  nervous  sub- 
stance, though  uratic  deposits  have,  in  rare  instances, 
been  detected  in  the  meninges  and  in  the  meningeal  fluids 
{cf.  Rendu).  Dr.  Buzzard  believes  that  they  may  occur  in 
the  lymphatics  of  peripheral  nerves,  and  set  up  a  gouty 
neuritis.  Sir  W.  Wade's*  neural  theory  of  gout  is 
founded  upon  this  assumption. 

Of  the  frequent  association  of  a  gouty  history  and 
of  goutiness  with  the  severest  form  of  neuralgia,  tic 
douloureux,  and  with  a  great  variety  of  neuralgise,  includ- 
ing hemicrania  and  sick-headache,  and  of  minor  nerve 
symptoms,  there  cannot  be  a  doubt.  Many  neurotic 
conditions  are  ascribed  to  gouty  influences,  perhaps  cor- 
rectly ;  but  we  should  not  lose  sight  of  the  insecure 
character  of  this  inference  so  long  as  it  remains  a  purely 
clinical  one. 

A  complete  account  of  all  the  varieties  of  nervous 
ailments  which  have  been  attributed  to  gout  cannot  be 
attempted  here.  The  sum  of  what  we  know  is  but  small, 
and  may  be  arranged  under  the  headings  of  the  anato- 

*  C/.  p.  257. 


GOUTY  CEREBRAL  AFFECTIONS  245 


mical  divisions  of  the  nervous  system.  In  each  category 
we  meet  with  two  types  of  ailment,  the  organic  and  the 
neurotic,  but  the  hne  between  them  cannot  always  be 
firmly  traced. 

GOUTY  CEREBRAL  AFFECTIONS. 

The  Organic  Cerebral  Affections. — Apoplexy  and  cerebral 
degeneration,  however  frequent  in  the  subjects  of  inveterate 
gout,  are  not  in  themselves  gouty  events.  The  arterial 
disease,  their  immediate  cause,  though  it  may  be  influenced 
by  gout,  has  often  a  different  origin.  Nevertheless,  the 
clinical  events  are  capable  of  bearing  a  distinct  relation 
to  articular  gout,  through  the  occurrence  of  metastatic 
cerebral  congestions  determining  a  vascular  rupture.  The 
same  mechanism  which  is  observed  in  a  sudden  suppres- 
sion of  a  gouty  inflammation  may  also  explain  apoplexy, 
where  undue  strain  has  been  thrown  upon  the  excitable 
circulation  of  a  gouty  subject  by  mental  shock,  overwork, 
or  other  excitement ;  and  this  points  to  obvious  con- 
clusions in  practice. 

Gout  in  Hemiplegia. — It  is  well  known  that  articular 
gout  supervening  upon  hemiplegia  usually  attacks  the 
paralyzed  Hmb.  Cases  of -this  sort  have  been  under  the 
observation  of  every  hospital  physician.  Sir  Dyce  Duck- 
worth draws  attention  to  the  fact  that  the  rule  is  not 
absolute  ;  he  gives  an  instance  of  the  incidence  of  gout 
on  the  non-paralyzed  limb,  and  another  instance  in  which 
both  limbs  were  affected. 

Cerebral  and  Meningeal  Congestion.  —  Extensive  and 
severe  congestions  are  themselves  closely  associated  with 
organic  results,  and  may  be  fitly  considered  under  this 
category,  however  closely  allied  they  are  to  those  more 
limited  vaso-motor  disturbances  which  must  underlie  the 
neuroses  to  be  presently  described.     The  genuineness  of 


246  GOUTY  CEREBRAL  AFFECTIONS 

the  occurrence  of  intercranial  congestion  on  the  too 
sudden  suppression — especially  by  cold  applications — of 
the  acute  articular  symptoms  is  attested  on  sufficiently 
reliable  authority  to  be  accepted  as  a  fact. 

Moreover,  the  symptoms  tell  us  of  the  nature  of  the 
process ;  they  consist  of  violent  headache,  drowsiness  or 
stupor,  convulsions  or  vertigo.  By  the  side  of  these  less 
unusual  results,  extraordinary  cerebral  phenomena,  occa- 
sionally observed  in  articular,  but  chiefly  in  retrocedent 
gout,  have  been  attributed  to  similar  congestions,  though 
the  evidence  on  which  this  inference  is  based  may  not  be 
considered  sufficient  to  exclude  the  alternative  inference 
of  a  possible  ischsemia. 

Gouty  Cerebral  Encephalopathy. — Under  this  one  term, 
which  is  a  sufficiently  neutral  pathological  expression  to 
fit  all  varieties  of  these  obscure  and  hitherto  inexplicable 
phenomena,  have  been  included  the  whole  group  of  alarm- 
ing, though,  happily,  relatively  harmless  cerebral  seizures. 
Roughly,  they  may  be  divided  into  two  groups : 

1.  The  hemiplegic  form  presents  characters  sufficiently 
indicated  by  its  name.  In  this  case  the  metastatic  process 
sets  up  symptoms  which  may  simulate  apoplexy  so  closely 
that  their  complete  cessation  after  a  few  days  may  be  the 
only  means  of  identifying  their  independence  from  any 
hsemorrhagic  lesions.  Rendu,  who  does  not  doubt  that 
they  are  due  to  localized  cortical  congestions,  quotes 
two  of  the  cases  reported  by  Lynch,*  and  one  by 
Brongniart."!* 

2.  The  aphasic  or  amnesic  form  is  much  more  common  and 
less  severe.  There  may  be  slight  alternation  of  conscious- 
ness, or  even  slight  convulsions  ;  but  the  characteristic 
event  is   the   more  or  less    marked   aphasia   or   amnesia 

*  Dublin  Quarterly  Journal,  1856. 

t  'Contribution  k  I'Histoire  de  la  Goutte  Viscerale';  Paris,  1875. 


GOUTY  SPINAL  AFFECTIONS  247 

which,  when  first  observed,  often  suggests  the  possible 
occurrence  of  some  shght  Hmited  haemorrhage  in  connec- 
tion with  the  speech  centres.  The  symptoms,  however, 
will  disappear  completely  after  the  lapse  of  a  few  days. 

Cerebral  Neuroses. — Severe  ailments,  such  as  insanity, 
melancholia,  hypochrondriasis,  and  epilepsy,  sometimes 
originate  as  apparent  metastases  of  gout.  The  same  is 
undoubtedly  true  of  vertigo.  Insomnia  is  common  among 
gouty  subjects. 

We  must  also  include  here  some  of  the  minor  forms 
belonging  to  the  previous  group.  When  clearly  meta- 
static, these  remarkable  attacks  of  transient  unconscious- 
ness, of  amnesia^  of  aphasia,  or  of  threatened  hemiplegia, 
have  been  naturally  attributed  to  limited  congestions, 
though,  as  stated  above,  this  mode  of  causation  is  open  to 
some  doubt.  On  the  other  hand,  the  slighter  forms  are 
sometimes  noticed  independently  of  any  acute  gouty 
arthritis,  and  must  then  be  classified  as  neuroses,  and 
regarded  as  instances  of  the  neurotic  manifestations  of 
goutiness. 

GOUTY  SPINAL  AFFECTIONS. 

The  attempt  is  made  by  Rendu*  to  trace  to  gout  con- 
ditions of  the  spinal  cord  analogous  to  those  affecting  the 
brain.  It  will  be  seen  that  the  clinical  evidence  is  singu- 
larly meagre. 

Gouty  spinal  apoplexy  is  represented  by  a  single  case  of 
Critchett  and  Curling,  who  described  a  rapidly  fatal  para- 
plegia in  a  gouty  subject,  caused  by  a  haemorrhage  in  the 
upper  section  of  the  spinal  cord.  In  this  case  the  con- 
nection with  gouty  symptoms  is  not  shown  to  have  been 
immediate. 

Gouty  Spinal   Myelitis. — Graves   believed   that   myelitis 

*  Loc.  cz'f.,  p.  120  et  seq. 


248  GOUTY  SPINAL  AFFECTIONS, 

might  be  induced  by  the  extension  to  the  cord  of  a  gouty 
neuritis  ;  he  based  this  opinion  upon  the  cKnical  and  post- 
mortem study  of  two  cases.  Here,  again,  the  evidence 
hardly  affords  adequate  support  for  the  conclusions. 
Todd  also  reported  a  case  of  paraplegia  supervening 
immediately  after  an  acute  attack  in  the  feet.* 

Gouty  Congestive  Paraplegia. — The  possibility  of  meta- 
static congestions  producing  in  the  spinal  cord  disturb- 
ances analogous  to  those  of  gouty  encephalopathy  is 
equally  unsupported  by  strict  evidence.  Rendu  adduces 
a  case  reported  by  Begbie,t  in  which  an  incomplete  para- 
plegia presented  temporary  aggravations  which  were 
attributed  to  recurring  local  congestions  of  the  cord. 
Ollivier's  casej  was  that  of  a  man  aged  forty-five,  in  whom 
gouty  deposits  were  found  in  the  spinal  dura  mater ;  the 
pia  mater  and  the  cord  itself  were  sound.  The  symptoms 
observed  were  thought  to  have  probably  been  adduced  by 
gouty  congestive  attacks  in  the  gray  matter.  Greater 
weight  may  be  attached  to  Dr.  Wilks'§  case,  in  which 
complete  paraplegia,  with  bedsore  and  vesical  symptoms, 
etc.,  set  in  after  a  gouty  attack,  and  ultimately  recovered. 
It  was  regarded  as  a  metastasis  by  Dr.  Wilks.§  Duck- 
worth,f  who  quotes  this  case,  believes  that  a  paraplegia 
may  follow  or  may  precede  a  gouty  attack,  and  may  be  so 
complete  as  to  involve  the  sphincters,  and  yet  be  re- 
covered from.l 

From  such  imperfect  evidence  as  the  above  we  are 
unable  to  decide  in  favour  of  the  view  that  gout  is 
responsible  for  any  definite  spinal  affections. 

*  'Cyclopedia  of  Anatomy  and  Physiology,'  1839,  vol.  iii.,  p.  121, 
quoted  by  Rendu. 

f  'Contributions  to  Practical  Medicine,'  1862. 

±  'Archives  de  Physiologic,'  2^^<^  serie,  t.  v.,  p.  455,  1878. 

§  '  Diseases  of  the  Nervous  System,'  1878,  p.  229. 

II   Cf.  Duckworth,  loc.  cit.,  pp.  98,  238. 


GOUTY  MEDULLARY  AFFECTIONS  249 

GOUTY  MEDULLARY  AFFECTIONS. 

In  connection  with  the  medulla  oblongata,  we  are  re- 
stricted to  the  functional  group  of  neuroses,  and  in  par- 
ticular to  those  of  the  respiratory  and  alimentary  tracts, 
and  of  the  cardiac  and  vaso-motor  systems. 

Reference  has  already  been  made  to  the  cardio-vascular 
affections  which  have  been  observed  in  association  with 
gout. 

Among  the  respiratory  neuroses,  asthma  is  notoriously 
common  among  those  predisposed  to  gout  by  heredity ; 
and  hay-fever  is  regarded  by  some  as  partaking  of  the 
same  gouty  bias. 

Neuroses  of  the  circulatory  system  are  often  attributed  to  a 
gouty  factor.  The  connection  in  question  is  probably 
more  often  capable  of  proof  in  the  case  of  the  peripheral 
vasomotor  phenomena  (tingling,  numbness,  etc.)  than  in 
the  cardiac  neuroses,  such  as  Graves'  disease,  tach3xardia, 
bradycardia,  and  pseudo-angina.  Organic  angina  pectoris 
doubtless  attacks  gouty  subjects,  but  is  not,  anymore  than 
the  atheroma  to  which  it  is  due,  specifically  gouty. 

Neuroses  of  the  Alimentary  Tract.  —  CEsophagismus, 
hiccough,  gastralgia,  paroxysmal  gastric  Hatulent  disten- 
sions, heartburn,  acute  nervous  dyspepsia  (both  gastric 
and  duodenal),  colic,  and  irregular  action  of  the  bowels,  are 
some  of  the  functional  disorders,  elsewhere  referred  to,  to 
which  gouty  subjects  are  liable. 

The  stomach  is  the  seat  of  the  most  common  and  of  the 
most  severe  metastatic  disturbances,  which  are  in  part 
nervous  phenomena.  Vertigo,  as  it  occurs  in  gout,  is  in  a 
majority  of  instances  a  gastric  reflex,  although  in  some 
cases  it  may  be  associated  with  other  nervous  symptoms 
suggestive  of  a  central  origin. 


250     GOUTY  AFFECTIONS  OF  PERIPHERAL  NERVES 

GOUTY  AFFECTIONS  OF  PERIPHERAL  NERVES. 

The  peripheral  nervous  system  supphes  instances  of 
both  the  organic  and  neurotic  kind. 

Gouty  Neuritic  Varieties. — Peripheral  neuritis  itself  had 
not,  since  Graves  wrote,  been  definitely  accredited  v^^ith  a 
gouty  aetiology,  until  the  subject  was  recently  revived  by 
Dr.  Buzzard,*  who  describes  cases  beginning  with  *  pins 
and  needles,'  and  leading  to  muscular  wasting  and  to 
changes  in  the  electric  reactions,  which  he  was  able  to 
trace  to  gout,  and  to  relieve  by  appropriate  treatment. 
In  connection  with  them,  he  suggests  the  probability  of 
uratic  deposits  in  the  lymph  channels  of  the  nerve- 
sheaths. 

The  same  subject  is  dealt  with  by  Sir  Dyce  Duck- 
worth,-}- who  finds  that,  next  to  the  great  sciatic,  the 
branches  of  the  brachial  plexus  are  the  most  commonly 
affected ;  and  he  refers  the  symptoms  to  an  inflammation 
of  the  perineurium,  with  effusion  into  the  sheath. 

The  inveterate  neuralgia  following  herpes  zoster,  an 
affection  regarded  by  various  authorities  as  commonly  of 
gouty  origin,  is  probably  often  connected  with  structural 
changes  akin  to  neuritis. 

Under  the  broad  heading  of  neuralgice  instances  of  both 
varieties  may  be  found.  Perhaps  one  of  the  most  common 
and  most  severe  of  those  neuralgise  which  may  be  termed 
neuritic  is  sciatica ;  and  gout  is  usually  admitted  as  being 
often  the  cause.  At  the  same  time,  it  is  generally  held 
that  some  forms  of  sciatica  are  largely  or  entirely  neurotic. 

Again,  in  trifacial  neuralgia,  also  frequentl}^  gouty,  a 
neurotic  element  is  undeniable.  But  the  inveteracy  and 
almost  incurable  character  of  the  affection  warrants  the 

*  'Paralysis  from  Peripheral  Neuritis,'  1886. 
t  Loc.  cit.,  p.  305. 


GOUTY  AFFECTIONS  OF  PERIPHERAL  NERVES    251 

view  that  structural  changes  also  form  part  of  it,  and  this 
is  partly  borne  out  by  the  success  which  the  writer  has 
found  in  a  treatment  by  those  remedies  which  promote 
absorption. 

Gouty  Neurosal  Varieties.  —  Most  of  the  common 
neuralgicB  belong  to  the  neurosal  group :  the  supra-orbital, 
the  occipital,  the  cervico-brachial,  the  intercostal,  and  the 
sciatic  neuralgise  are  those  most  frequently  observed.  They 
are  easily  excited  in  gouty  subjects  by  comparatively 
trifling  irritations,  and  not  easily  relieved  except  by 
appropriate  treatment,  or  by  the  supervention  of  an 
articular  attack. 

Fugitive  pains,  often  of  considerable  intensity,  are  apt  to 
occur  in  various  situations  in  direct  association  with  the 
liability  to  the  articular  manifestations,  the  advent  of  the 
latter  causing  their  immediate  cessation.  They  probably 
originate  from  irritation  of  nerve-fibrils,  and  this  is 
rendered  the  more  probable  by  the  diversity  of  the  tissues 
which  are  their  apparent  seat.  Sir  Dyce  Duckworth, 
who  has  bestowed  much  attention  upon  this  subject,* 
attributes  them  to  '  a  temporary  local  stasis  of  sodium 
urate,'  and  draws  attention  to  their  having  been  recognised 
as  truly  gouty  by  Anstie,t  who  was  not  a  believer  in  a 
gouty  causation  of  neuralgia.  Gairdner  had  long  ago 
described  cases  of  this  sort. 

Gouty  cramp  is  regarded  by  Rendu  as  induced  by  a  local 
nerve  irritation. 

Fugitive  peripheral  paralysis  also  belongs  to  the  neurosal 
category.  Garrod|  mentions  a  case  of  facial  palsy  which 
disappeared  on  the  occurrence  of  regular  gout.  A  similar 
case  of  temporary  neuralgic  paralysis  of  the  lower  limb, 

*  'St.  Bartholomew's  Hospital  Reports,'  1879,  vol.  xv.,  and  loc. 
cit.,  p.  230. 

t  'Neuralgia  and  its  Counterfeits,'  1871.  %  Loc.  cit.,  p.  548. 


252     GOUTY  AFFECTIONS  OF  PERIPHERAL  NERVES 

which  was  dispelled  by  articular  gout,  was  observed  by 
Graves. 

Fugitive  vaso -motor  phenomena  of  ischsemic,  hypersemic, 
or  oedematous  type  form  a  very  large  aggregate  of  minor 
ailments,  not  exclusively  gouty,  but  often,  indeed,  observed 
in  goutiness.  Their  detailed  clinical  description  need  not 
here  be  entered  upon. 

Megrim  is  not  to  be  classed  among  the  common 
neuralgise,  being  rather,  according  to  Dr.  Edward 
Liveing's  happy  description,  a  '  nerve  storm.'  It  is  not, 
therefore,  a  neuritis,  but  a  neurosis,  probably  originating 
in  the  medulla,  and  running  its  course  peripherally.  Dr. 
Liveing  has  recognised  its  frequent  8.ssociation  with  a 
gouty  tendency ;  and  Duckworth  regards  it  as  attacking 
the  subjects  of  inherited  goutiness,  rather  than  sufferers 
from  actual  gout.  Dr.  Haig  attributes  it  to  the  presence 
of  an  excess  of  uric  acid  in  the  blood. 

Entirely  different  is  the  simple  gouty  headache,  which 
Duckworth  describes  as  being  imperfectly  localized  and 
alternating  with  articular  attacks. 

GOUTY  AFFECTIONS  OF  MUSCLES. 

The  uratic  infiltration  of  the  tendons  adjoining  gouty 
joints  may  extend  into  the  muscles.  The  recorded 
occurrence  of  a  uratic  deposit  in  the  myocardium  opens 
up  the  possibility  of  intramuscular  deposits  occurring  at  a 
distance  from  joints.  Hitherto  the  clinical  events  have 
not  been  traced  to  any  definite  lesions. 

The  symptoms  observed  in  gout  are  of  the  painful  and 
of  the  spasmodic  variety.  Lttmbago,  intercostal  rheumatism-, 
and  other  painful  inyalgics,  have  often  been  regarded  as 
more  closely  allied  to  gout  than  to  rheumatism.  Most 
probably  they  are  due  to  an  affection  of  the  fibrous,  rather 


GOUTY  AFFECTIONS  OF  MUSCLES  253 

than  of  the  contractile,  elements  of  muscle.  Cramp  is  one 
of  the  most  familiar  features  in  gout,  occurring,  as  stated 
by  Garrod,  as  a  premonitory  symptom  of  the  acute  attack, 
and  also  as  one  of  the  attendant  symptoms  of  goutiness. 
Both  in  gouty  cramp  and  in  the  gouty  myalgia  it  is  an 
open  question  whether  the  cause  leading  to  the  painful 
contraction  or  stiffness  may  not  reside  in  the  irritation  of 
nerve-fibrils  distributed  to  the  fibrous  tissue,  rather  than 
in  any  direct  irritation  of  the  muscular  tissue  itself. 
Among  the  spasmodic  affections  may  perhaps  be  men- 
tioned the  unnatural  grinding  of  teeth  during  sleep  which 
was  described  by  Graves,  and  cases  of  which  have  been 
recorded  by  other  authorities. 


CHAPTER  XXIX. 

SIR  WILLOUGHBY  WADE'S  NEURAL  THEORY. 

Sir  WillougHby  Wade's  investigations*  were  suggested 
by  a  consideration  of  the  multiplicity  of  the  phenomena 
indicating  the  nervous  system  as  implicated  in  gout,  and 
of  the  absence  of  any  precise  indication  that  any  one 
portion  of  the  central  nervous  system  is  directly  or  in- 
directly identified  with  its  production. 

SIR  W.  WADE'S  CLINICAL  OBSERVATIONS. 

The  Lines  of  Tenderness  over  the  Gouty  Joints.  —  The 
earliest  observation  was  that  of  a  '  patchy  '  tenderness  of 
the  skin  in  acute  gouty  arthritis,  without  any  corresponding 
differences  in  the  appearance  of  the  localized  tender  areas. 
Subsequent  investigations  defined  these  areas  into  narrow 
lines  of  acute  tenderness.  In  the  case  of  the  ^reat  toe,  the 
tender  line  extends  beyond  the  zone  of  redness  and  swelling 
slantingly  upwards  to  the  bend  of  the  ankle,  in  the  area  of 
distribution  of  the  nerve  to  which  Sir  W.  Wade  refers  as 
No.  4.t 

*  '  On  Gout  as  a  Peripheral  Neurosis,'  by  Sir  Willoughby  Wade, 
M.D.,  F.R.C.P.,  Consulting  Physician  to  the  General  Hospital,  Bir- 
mingham. London  :  Simpkin,  Marshall,  Hamilton,  Kent  and  Co., 
Limited.     Birmingham  :  Cornish  Brothers,  New  Street.     1893, 

f  ' "  No.  4  is  a  division  of  the  dorsal  branch  of  the  peroneal  nerve 
giving  filaments  to  the  foot,  the  inner  side  of  the  great  toe,  the  outer 


WADE'S  CLINICAL  OBSERVATIONS  255 

Sir  W.  Wade  satisfied  himself  that  this  tenderness  could 
not  be  referred  to  the  tendon  of  the  long  extensor  of  the 
great  toe,  nor  to  the  veins,  though  the  latter  are  apt  to  be 
tender  on  pressure,  or,  at  any  rate,  the  skin  over  them. 

Not  only  was  there  no  tenderness  in  the  intervals  between 
the  lines  specified,  but  movement  of  the  joint  itself  gave 
no  pain,  even  though  the  bones  were  brought  against  each 
other  with  considerable  pressure. 

In  the  hands,  Wade  recognises  four  situations  in  which 
gouty  attacks  may  occur  separately  or  simultaneously  : 
(i)  the  knuckles  ;  (2)  the  back  of  the  hands  ;  (3)  the  ball 
of  the  thumb  ;   (4)  the  hypothenar  region. 

In  the  hypothenar  region  a  tender  point  is  found  on  the 
radial  side  of  the  pisiform  bone.  Another  tender  spot  is 
the  interval  between  the  two  extensors  of  the  thumb.  A 
third  seat  of  tenderness  is  the  centre  of  the  dorsum  of  the 
wTist,  where  a  branch  from  the  ulnar  joins  one  from  the 
radial  nerve.  Lastly,  at  the  wrist-joint  the  ulnar  nerve 
gives  off  a  deep  branch*  which  supplies  the  metacarpo- 
phalangeal joints  of  the  ring  finger,  of  the  second  finger, 
and  of  the  fourth  finger.  Wade  also  found  tenderness  in 
the  nerves  which  run  one  on  each  side  along  the  dorsum 
of  the  fingers,  and  one  on  each  side  on  their  palmar  aspects. 
General  tenderness  of  the  fingers  may,  however,  render 
the  sites  of  these  nerves  difficult  to  distinguish. 

As  regards  the  aching  and  tenderness  so  often  present  in 
the  great  toe  of  gouty  people,  this  can  be  shown  to  be 
independent  of  movement  of  the  joint,  and  entirely  con- 
nected with  pressure  on  the  inner  and  outer  branch  of  the 

side  of  the  second  and  the  inner  side  of  the  third  toes." — Swan,  "  De- 
monstration of  Nerves  of  the  Human  Body,"  Plate  XXIV.,  Fig.  2. 
No.  4  nerve  divides  at  the  middle  of  the  lower  border  of  the  anterior 
annular  ligament  into  two  branches — one  slanting  across  to  the  base 
of  the  great  toe,  the  other  proceeding  to  the  other  toes.' 
*  Swan,  Plate  XXII.,  Fig.  2,  No.  28., 


256  WADE'S  CLINICAL  OBSERVATIONS 

internal  plantar  nerve,  and  the  tenderness  extends  also 
up  and  down  their  course. 

The  '  side  tenderness '  of  the  great  toe  is  probably  due 
to  the  internal  branches  of  the  peroneal  (i.e.,  external 
popliteal  nerve). 

In  the  so-called  plantar  tenderness  Wade  has  found  a 
line  of  tenderness  near  the  inner  margin  of  the  sole  where 
a  nerve  lies  to  which  he  refers  as  branch  5.* 

The  heel  is  supplied  in  its  inner  half  by  the  posterior 
tibial  nerve,  behind  the  inner  ankle  ;  its  outer  half  is  sup- 
plied from  behind  the  outer  ankle  by  a  joint  branch  from 
the  communicating  tibial  of  the  sciatic,  and  from  the 
cutaneous  of  the  peroneal.'!' 

Undue  tenderness  in  any  of  these  situations,  even  in  the 
absence  of  conscious  gouty  feelings,  points  to  goutiness, 
and  may  enable  us  to  identify  as  gouty  some  otherwise 
unexplained  visceral  symptoms.  It  is  noteworthy  that, 
like  the  pains  of  gout,  the  tenderness  may  be  fugitive. 

The  cBtiological  influence  of  injuries  is  studied  in  different 
sets  of  cases.     Different  degrees  are  recognised  : 

(a)  That  of  severe  sprains,  bruises,  or  blows,  i.  The 
result  may  be  immediate  or  long  delayed.  During  the 
interval  there  may  or  may  not  be  freedom  from  symptoms 
due  to  the  accident  itself,  2.  In  some  cases  other  joints  are 
affected  also,  but  these  have  not  been  found  affected  in- 
dependently of  the  injured  one. 

{h)  As  instances  of  minor  influences  of  the  same  kind 
are  noticed  :  i.  The  determination  or  reproduction  of 
joint  trouble  by  use  of  the    part,     2.    The  influence  of 

*  '  Swan  describes  (Plate  XXV,,  Fig.  3,  No.  8)  a  branch  of  the 
branch  5  of  the  inner  plantar  nerve  terminating  in  the  joint  of  the 
great  toe,  between  the  metatarsal  bone  and  the  first  phalanx.'  This 
branch  5  has  been  already  referred  to  as  running  on  the  inner  side  of 
the  inferior  aspect  of  the  great  toe. 

t  Swan,  Plate  XXV.,  Fig.  2,  Nos.  20  and  21. 


WADE'S  NEURAL  THEORY  257 

pressure,  e.g.,  a  persistence  for  three  days  of  redness  and 
tenderness  of  the  heel,  where  it  had  been  bearing  upon 
the  opposite  instep.  3.  That  of  cold  and  wet  feet,  just 
as  gouty  inflammation  may  settle  in  a  mucous  membrane 
from  cold.  4.  Both  neuritis  and  neuralgia  may  also  be 
produced.  5.  '  Gout  in  the  stomach,'  according  to  Sir 
Thomas  Watson,  '  resolves  itself  often  under  the  influ- 
ence of  an  emetic  into  pork  in  the  stomach.'  Taking 
another  view,  this  would  be  an  instance  of  visceral  gout 
being  set  up  by  a  local  irritant. 

SIR   W.  WADE'S  THEORY. 

As  to  the  local  nerve  conditions,  Sir  W.  Wade  notes 
merely  their  general  resemblance  to  those  of  neuralgia, 
hypersemia,  and  neuritis  of  the  acute  and  chronic  form. 
Hypersemia  of  nerves  is  the  basis  of  some  neuroses,  whilst 
neuralgia  and  neuritis  are  among  the  recognised  train  of 
gouty  symptoms. 

Wade  inclines  to  regard  the  conditions  he  has  described 
as  essentially  neuritic.  Of  neuritis  he  recognises  two  types, 
implicating  respectively  the  conducting  grey  matter  and 
the  protective  coverings,  along  two  lines  of  extension :  more 
commonly  the  upward  extension,  as  in  neuritis  ascendens, 
the  influence  sometimes  travelling  up  as  far  as  the  cord 
itself,  and  sometimes  the  downward  extension,  as  in 
neuritis  descendens. 

In  the  aetiology  and  in  the  clinical  features  there  are 
strong  analogies  between  the  gouty  symptoms  and  the 
classical  neuritis  :  for  instance,  the  more  intense  and 
early  implication  of  the  sensory  nerves  ;  the  fact  that  the 
sensitiveness  to  pressure  is  constant,  not,  as  in  neuralgia, 
inconstant ;  the  trophic  disturbances  of  the  skin,  nails,  and 
joints  (glossy  skin,  etc.) ;  and  the  vaso-motor  disturbances. 

17 


258  WADE'S  NEURAL  THEORY 

Attention  is  also  called  to  a  degeneration,  of  toxic 
origin,  of  the  white  substance  and  of  the  axis  cylinder. 
The  painlessness  of  diphtherial  neuritis  is  attributable  to 
the  absence  of  changes  in  the  neurilemma. 

In  conclusion,  Cullen  had  taught  us  the  intimate  con- 
nection between  gout  and  the  nervous  system ;  the  con- 
necting bond,  according  to  Wade,  is  in  the  peripheral 
nerves. 

Returning  to  a  consideration  of  the  acute  local  gottty 
attack,  Wade  distinguishes  two  sets  of  cases.  In  one  of 
them  he  regards  the  neuritis  as  set  up  by  primary  inflam- 
mation of  the  joint.  In  another  class  he  finds  a  neuritis 
present,  but  arthritis  absent.  Thus,  he  mentions  the  con- 
current presence  in  a  patient  of  a  gouty  affection  of  the 
thumb  without  arthritis,  and  of  a  gouty  affection  of  the 
fingers  with  arthritis  and  effusion. 

The  evidence  of  the  priority  of  the  nerve  disorder  is  to 
be  traced  in  the  sensory,  the  vaso-motor,  and  the  trophic 
changes.  The  missing  link  in  the  demonstration  is  the 
proof  of  a  pre-existing  neuritis  culminating  in  a  frank 
arthritic  attack.  This  link  should  be  sought  by  careful 
observers.  One  difficulty  is  often  that  of  determining 
whether  an  instance  of  tenderness  due  to  an  inflamed 
nerve  fibril  is  or  is  not  connected  with  a  joint  inflammation. 
The  tender  nerve  renders  the  part  as  a  whole  intolerant 
of  the  slightest  movement,  though  the  joint  may  not  be 
afl"ected. 

Sir  W.  Wade's  Theory  of  Goid. — Taking  a  view  of  the 
whole  subject  of  gout.  Wade  assumes  an  aberration  of  the 
metabolism  of  proteids  (a  hypo-metabolism  or  para- 
metabolism  of  unknown  cause,  origin,  and  stages).  Mean- 
while, quadriurate  of  sodium  lowers  the  alkalinity  of  the 
blood.  There  may  be  also  other  by-products,  terminal  or 
collateral,  besides  the  excess  of  uric  acid. 


WADE'S  NEURAL  THEORY  259 

The  disturbance  of  metabolism  is  induced  by  excessive 
mental  strain,  or  by  the  use  of  certain  foods,  or  of  alcohol 
— particularly  in  the  form  of  fermented  malt  liquors,  or  of 
strong,  highly  -  saccharated,  hyperacid,  or  effervescing 
wines  of  high  setherial  percentage.  By  this  faulty  blood 
state  the  stability  of  the  nerve-trunks  is  impaired,  and  they 
are  laid  open  to  influences  which  would  be  inoperative  on 
normal  nerves. 

These  are  the  combined  intrinsic  and  extrinsic  influences 
leading  up  to  neuralgia  or  neuritis.  The  further  effects 
are  determined  by  the  intensity  of  the  neuropathy,  by  the 
endowments  of  the  nerve  affected  (whether  sensory,  vaso- 
motor, trophic,  or  motor),  by  its  territorial  distribution, 
and  by  the  simultaneous  implication  of  two  or  more  classes 
of  nerves.  The  blood  poison  seems  to  possess  an  elective 
aflinity  for  the  various  classes  in  the  order  stated. 

The  neuropathy  is  enhanced  by  any  sudden  increase  in 
the  blood  dyscrasia,  owing  to  (i)  an  aggravation  of  the 
cause  which  disturbs  the  metabolism  —  and  it  may  be 
noted  that  the  highest  and  the  lower  cerebral  centres  may 
conceivably  influence  metabolic  activity  ;  (2)  a  liberation 
into  the  blood  of  the  morbid  products  stored  up  in  some 
part  or  viscus ;  and  (3)  a  diminution  in  the  eliminative 
function  of  some  organ  or  organs  which  should  have 
separated  these  products  from  the  blood. 

The  properties  of  a  neuritis,  of  ascending  or  of  descend- 
ing from  its  primary  seat,  and  in  this  way  even  of  affect- 
ing the  spinal  centres,  or  of  radiating  to  the  periphery, 
belong  to  this  neuropathy.  On  the  other  hand,  the 
central  nervous  centres  may  originate  or  aggravate  the 
general  gouty  condition  by  their  influence  over  '  recognised 
seats  of  metabolic  activity.'  They  may  also  determine 
local  outbreaks  through  the  agency  of  vaso  -  motor 
nerves. 


26o.  WADES  NEURAL  THEORY 

The  higher  cerebral  centres  are  also  liable  to  suffer  from 
the  blood  dyscrasia  (ill-temper,  melancholia,  etc.)- 

Visceral  gout  may  be  associated  with  local  deposition  of 
the  biurate,  analogous  to  that  in  the  joints.  Since  in  the 
latter  the  deposition  is  neither  necessary  nor  invariable  in 
gout — no  deposit  being  sometimes  found  in  a  joint  which 
had  been  repeatedly  affected,  whilst  a  deposit  may  be  found 
long  years  after  the  occurrence  of  a  single  attack  in  any 
given  joint,  and  that  the  deposit  might  therefore  be  looked 
upon  as  an  epiphenomenon — its  inconstancy  in  visceral 
gout  is  nothing  more  than  might  be  expected. 

In  what  way  an  attack  may  be  transferred  from  a  joint 
to  some  internal  part,  and,  again,  why  there  should  be, 
after  an  articular  seizure,  a  total  or  permanent  cessation 
from  those  symptoms  which  are  supposed  to  depend  upon 
impurity  of  blood,  there  is  at  present  no  evidence  to 
show. 

Arguments  in  Favour  of  the  'Neural  Theory.'' — Sir  W.  Wade 
has  restated  the  neural  theory,  hitherto  discredited  by  its 
vagueness,  in  a  form  which  is  definite,  concrete,  and 
tangible.  Neuritis,  which  is  advanced  as  the  principal 
change,  may  be  directly  concerned  in  implicating  the 
spinal  centres,  and  in  influencing  the  cerebral  centres. 
On  the  other  hand,  it  does  not  exclude  the  direct  influence 
exercised  by  the  highest  cerebral  centres  in  determining 
the  seizures,  an  influence  which  cannot  be  gainsaid,  though 
it  is  as  yet  inexplicable. 

Another  plea  is  that  the  theory  fits  better  than  any  other 
with  the  clinical  facts.  For  instance,  the  excessive  liability 
of  the  great  toe  to  acute  attacks  is  better  explained  by 
pressure  on  the  nerves  beneath  and  above  the  joint,  and 
by  neuritis,  than  by  the  alleged  influence  of  remoteness 
from  the  heart  (this  being  precisely  the  same  in  the  case 


WADE'S  NEURAL  THEORY  261 

of  the  other  toes),  or  of  the  incidence  on  this  joint  of  the 
weight  of  the  body,  the  latter  bearing  with  almost  equal 
force  on  the  ankle. 

Again,  the  absence  of  any  uratic  infiltration  in  a  joint 
which  has  suffered  from  repeated  attacks  supports  the  view 
that,  in  an  ordinary  local  seizure,  there  are  two  elements — 
an  inflammation  of  the  joint,  and  an  inflammation  of  the 
neighbouring  soft  parts.  One  of  these  can  possibly  occur 
without  the  other ;  indeed,  in  many  cases  the  actual 
existence  of  an  arthritis  is  matter  of  inference  only. 

It  is  certainly  noteworthy  that  the  earliest  and  severest 
attacks  involve  the  superficial  structures,  and  that  those 
associated  with  considerable  deposition  and  destruction 
present  a  minimum  of  inflammation  of  the  soft  parts, 
whilst  tophi  in  the  ears  (probably  induced  by  the  weight  of 
the  head  on  the  pillow)  occur  without  any  predisposing 
inflammation. 

The  rapid  disappearance  of  the  inflammation  from  the 
great  toe  under  the  influence  of  cold  affusion,  of  colchicum, 
or  of  other  means,  is  not  easily  explained  by  the  assump- 
tion that  its-  cause  is  the  mechanical  irritation  of  the 
biurate.  The  removal  of  the  latter  within  so  brief  a  space 
of  time  is  not  readily  conceived  ;  but  neuritis  would  explain 
the  clinical  result. 

Visceral  gout,  one  factor  of  which  is  '  the  gouty  poison  in 
the  blood,'  would  be  in  part  dependent  on  the  deteriora- 
tion of  the  local  nerves  under  the  influence  of  the  poison, 
at  least  of  such  nerves  as  possess  a  neurilemma. 


CHAPTER  XXX. 

RETROCEDENT   GOUT   AND   WANDERING 

GOUT,  AND  THE  PHENOMENA  OF 

IDIOSYNCRASY. 

GOUTY    METASTASIS. 

A  VISCERAL  crisis,  cerebral,  nervous,  pulmonary,  cardiac, 
or  gastric,  coinciding  with  the  abrupt  subsidence  of  an 
acute  joint  attack,  is  commonly  regarded  as  gouty,  and 
described  as  suppressed  or  as  retrocedent  gout.  The  two 
names  represent  two  pathological  views  of  the  events. 
According  to  one  of  them,  the  gouty  process  itself  is 
checked  ;  according  to  the  other,  it  persists,  the  gouty 
products  being  merely  diverted  from  the  joint  into  the 
less  favourable  channel  of  the  viscera.  Reference  has 
been  made  to  the  clinical  phenomena  of  the  chief  visceral 
metastases.  The  following  remarks  will  deal  with  some 
of  the  pathological  aspects  of  the  question. 

The  more  severe  metastases  occur  in  the  course  of  acute 
gout,  and  it  is  to  this  variety  that  the  terms  mentioned 
are  generally  applied.  Another  group  of  cases  is  con- 
nected with  the  milder  articular  manifestations,  or  with 
the  state  of  goutiness,  and  is  known  as  '  wandering  '  or 
'  flying '  gout.  The  first  of  these  is  becoming  infrequent  ; 
much  less  so  the  second.  The  acute  joint  attacks  are 
now  less  common,  and  a  revulsive  treatment  favouring 
metastasis  is  less  often  resorted  to  than  in  former  genera- 


GOUTY  METASTASIS  263 

tions.  Moreover,  angina  pectoris  and  locomotor  ataxy 
now  claim  a  proportion  of  the  mysterious  seizures  formerly 
recorded  as  metastatic.  This  has  caused  the  nature  of 
the  remaining  cases,  and  the  genuineness  of  gouty  meta- 
stasis itself,  to  be  called  in  question  ;  and  it  has  been 
suggested  that,  like  so  many  other  ancient  views,  retro- 
cedent  gout  might  be  a  traditional  error. 

We  should  not,  however,  too  hastily  dismiss  gouty 
metastasis  as  a  fable.  The  clinical  facts,  though  many 
of  them  are  old,  are  not  uniformly  unworthy  of  credence. 
Modern  literature  provides  us  with  occasional  instances 
which  will  compare  with  them  ;  indeed,  there  has  been  an 
unbroken  continuity  in  the  clinical  records  from  remote 
times  down  to  the  present  day,  and  many  are  sufficiently 
circumstantial  to  enable  us  to  gauge  their  value. 

Retrocedence  is  rendered  probable,  moreover,  by  the 
undeniable  genuineness  of  a  converse  process.  Sudden 
and  severe  visceral  crises  are  not  only  apt  to  replace  a 
retrocedent  arthritis  :  they  may  precede  the  latter,  and  be 
themselves  replaced  by  it.  In  the  latter  case  the  gouty 
influence  is  not  on  the  wane,  but  at  its  height  at  the 
time  of  the  visceral  seizure,  which  is  cut  short  by  the 
gouty  climax  in  the  joint.  This  is  probably  the  strongest 
argument  in  favour  of  the  gouty  complexion  of  the  whole 
group  of  the  retrocedent  and  of  the  wandering  visceral 
symptoms. 

THE  PHENOMENA  OF  IDIOSYNCRASY  :  A  PARALLEL 
WITH  METASTATIC  GOUT. 

Severe  and  unaccountable  symptoms,  independent  of 
gout,  are  sometimes  set  up  by  agencies  absolutely  harm- 
less to  normal  persons,  in  connection  with  individual 
peculiarity  or  idiosyncrasy.  Quite  irrespective  of  the  fact 
that    the    subjects   in    question    often    are   potentially   or 


264  THE  PHENOMENA   OF  IDIOSYNCRASY 

actually  gouty,  there  is  a  close  outward  resemblance 
between  the  phenomena  of  gouty  metastasis  and  some  of 
those  due  to  idiosyncrasy.  Commonly  the  idiosyncrasy 
consists  in  a  remarkable  intolerance  for  some  article  of 
diet,  which,  when  ingested,  may  cause  gastro-intestinal 
irritation.  In  others  there  is  abnormal  excitability  of  the 
nervous  system,  and  particularly  of  the  mucous  mem- 
branes of  the  organs  of  special  sense — as  in  asthma  and 
hay-asthma.  A  publication  of  the  following  instances  is 
kindly  permitted  by  Mr.  George  Pollock.* 

'  The  following  instance  was  related  to  me  by  the  late 
Dr.  Roupell.  A  relative  of  his  could  not  partake  of  rice 
without  most  alarming  symptoms.  .  .  .  Some  friends 
wished  to  test  the  truth  of  this  peculiar  or  supposed  effect 
of  rice,  and,  knowing  that  he  was  fond  of  biscuits,  had  some 
prepared  with  one  grain  of  rice  in  each.  These  biscuits 
were  placed  near  him  after  dinner,  and  he  partook  of  two 
or  three.  He  became  uncomfortable,  and  had  to  leave 
the  table,  observing  at  the  same  time  that,  if  he  were  not 
morally  certain  that  he  had  not  partaken  of  rice  at  dinner, 
he  was  being  poisoned  by  it.' 

'  Another  amusing  instance  is  that  of  a  man  who  could 
not  eat  gooseberries  without  their  producing  an  eczematous 
eruption  on  some  part  of  the  body.  When  dining  with  a 
fashionable  party,  soon  after  the  champagne  had  been 
handed  round,  he  observed  to  a  friend  sitting  next  him, 
that  the  wine  was  not  champagne,  but  gooseberry  wine, 
and,  pulling  up  his  shirt-sleeve,  showed  him  the  specific 
eczematous  rash  appearing.' 

'  Sir  Russell  Reynolds  has  sent  me  the  following  notes  : 
"  An  elderly  lady  and  patient  known  to   me  was  highly 

*  Cf.  'Address  delivered  at  the  Opening  of  the  Classes  of 
St.  George's  Hospital  Medical  School,  Session  1895-96/  by  George 
Pollock,  F.R.C.S. 


THE  PHENOMENA  OF  IDIOSYNCRASY  265 

susceptible  to  the  influence  of  opium  in  any  form,  even  to 
the  minutest  dose,  its  use  inducing  symptoms  hke  Asiatic 
cholera.  ...  In  prescribing  for  her,  when  suffering  from 
bronchial  catarrh,  I  put  in  ten  minims  of  compound 
tincture  of  camphor.  About  half  an  hour  after  I  was 
summoned,  and  found  that  she  had  been  vomiting  and 
purging,  and  was  in  a  state  of  collapse.  ...  In  this  case 
the  dose  of  opium  must  have  been  oVth  of  a  grain."  ' 

'  A  gentleman  has  sent  me  the  following  particulars  of 
his  own  case :  "  A  mere  spoonful  of  honey  will  cause 
sensations  of  indigestion  —  a  burning  sensation  in  the 
throat,  shortness  of  breath,  and  giddiness.  This  generally 
lasts  for  two  hours  after  having  tasted  the  honey.  Honey 
has  had  the  same  effect  on  me  ever  since  my  childhood."  ' 

'  Another  gentleman  writes :  "I  have  never,  at  any 
time,  been  able  to  partake  of  eggs,  in  any  shape  or  form 
of  cookery,  without  subsequent  very  unpleasant  results — 
violent  pain  and  sickness."  ' 

'  A  gentleman  always  had  to  avoid  turpentine,  as  it 
caused  his  skin  to  swell  and  blister,  accompanied  by  acute 
pain.  One  day  his  arm  swelled  suddenly,  and  the  swelhng 
was  so  great  that  in  the  end  the  coat-sleeve  had  to  be  cut 
open.  For  some  time  it  could  not  be  accounted  for,  as 
he  knew  he  had  not  come  in  contact  with  turpentine  in 
any  way.  In  the  end  it  was  found  out  that  the  sleeve  of 
his  coat  had  been  smeared  with  paint,  and  that  his  servant 
had  cleaned  it  with  the  obnoxious  liquid.' 

Whilst  lessening  our  scepticism  in  regard  to  gouty 
metastasis,  these  observations  aid  our  study  of  the  latter. 
The  conditions  related  are  almost  those  of  a  physiological 
experiment,  and  they  leave  no  doubt  as  to  the  nature  of 
the  irritant.  The  following  suggestions  arise  in  connec- 
tion with  them  : 

(i)  The  visceral  nervous  system  is  capable  of  reacting 


266  THE  PHENOMENA  OF  IDIOSYNCRASY 

with  a  maximum  intensity  to  minimal  irritations.  The  severe 
dynamic  disturbance  excited  by  such  imponderable  agents 
as  those  which  appeal  to  our  senses  of  taste  and  of  smell 
remind  us  of  the  violent  response  called  forth  by  the 
slighter  forms  of  superficial  irritation  of  the  larynx  {e.g., 
by  a  bread  crumb). 

The  alarming  prostration  often  produced  reminds  us 
of  the  phenomena  of  collapse  in  retrocedent  gout,  and 
throws  light  on  the  delicacy  and  apparently  purely  nervous 
reflex  mechanism  by  which  they  are  probably  con- 
ditioned. 

(2)  The  original  irritant  may  in  gout  be  not  less  subtle 
than  in  some  cases  of  idiosyncrasy,  such  as  that  in  which 
a  small  quantity  of  rice,  which  had  been  added  to  beer 
in  the  bottling,  led  to  severe  symptoms.*  The  latter 
case  shows  that  the  offending  material  may  be  a  soluble 
one,  and  that  the  gastro-intestinal  symptoms  need  have 
no  reference  to  difficult  digestion  of  solid  material.  Here, 
again,  we  are  compelled  to  conclude  that  the  influence 
was  mainly  exerted  on  the  nervous  system,  and  by  such 
soluble  or  volatile  material  as  might  be  extracted  from  a 
few  grains  of  rice. 

At  the  same  time,  both  in  instances  of  this  kind  and 
in  that  of  gouty  metastasis,  the  possibility  should  not  be 
overlooked  that  the  toxic  effects  may  be  due  to  some 
faulty  glandular  secretion  influenced  by  the  irritant, 
though  the  latter  (uric  acid,  say)  need  not  be  toxic. 

(3)  The  excitability  of  the  ciUaneous  and  mucous  nerve- 
mechanisms  under  minimal  irritation  is  also  exemplified. 
In  the  case  of  irritation  by  turpentine,  as  also  in  cases 
of  hay-fever,  the  associated  vaso-motor  action  is  also 
manifest. 

*  This  instance  was  related  to  the  writer  by  Mr.  Pollock,  on  the 
authority  of  Mr.  T.  W.  Nunn,  F.R.C.S. 


NA  TURK  A  ND  ME  CHA  NISM  OF  GO  UTY  ME  TA  ST  A  SIS    267 

THE  NATURE  AND  MECHANISM  OF  GOUTY 
METASTASIS. 

The  problem  of  visceral  gout  and  of  gouty  metastasis 
remains  yet  unsolved.  Any  adequate  explanation  should 
include  the  milder  and  less  definite  phenomena  of  wander- 
ing visceral  gout,  as  well  as  the  sudden  and  alarming 
visceral  crises.  Are  the  visceral  accidents  really  the 
direct  result  of  a  cessation  of  the  local  inflammation,  or 
are  both  the  local  check  and  the  visceral  complication 
simultaneous  results  belonging  to  a  given  phase  in  the 
development  of  the  gouty  process  in  some  constitutions  ? 
The  distinction  is  a  fine  but  not  an  overdrawn  one.  The 
patient  may  become  at  a  certain  period  of  his  gout 
specially  prone,  on  slight  provocation,  to  pulmonary,  to 
gastric,  or  other  troubles,  whilst  the  previous  violence  of 
his  articular  attacks  may  no  longer  prevail.  The  visceral 
trouble  is  still  a  gouty  trouble,  and  a  result  of  the  general 
weakness  produced  by  the  chronic  disease  ;  but  it  is  not 
in  a  true  sense  a  retrocedence.  It  is  a  direct  effect  of  the 
irritation  rather  than  of  the  gout. 

Between  these  two  views  it  is  difficult  to  pronounce, 
but  the  more  closely  we  analyze  the  recorded  cases,  the 
more  are  we  impressed  with  the  close  relationship  between 
the  local  and  the  visceral  manifestations.  The  cases 
belong  to  two  groups  mainly :  those  in  which  the  visceral 
complication  supervenes  on  the  abrupt  cessation  of  the 
articular  lesion  ;  and  others  in  which  the  visceral  trouble 
appears  first,  and  by  its  suddenness,  severity,  and  unex- 
plained and  intangible  causation,  is  for  a  few  hours  a 
diagnostic  puzzle,  after  which  the  wonder  subsides  into 
common  articular  gout.  Instances  are  given  in  the 
treatises  on  gout  by  Sir  A.  Garrod  and  by  Sir  Dyce 
Duckworth.     They  bear  strong  witness  to  the  genuine- 


268     NA  TURE  A  ND  MECHA  NISM  OF  GOUTY  MET  A  ST  A  SIS 

ness  of  the  gouty  connection,  for  we  are  now  agreed  that 
the  articular  attack  is  preceded  by  a  saturation  of  the 
blood  with  irritating  substances,  though  opinions  differ 
as  to  their  toxicity. 

Three  theories  might  be  proposed  in  explanation  of  the 
phenomena  of  metastasis.  The  influence  might  be  that 
of  a  mechanical  irritation,  of  a  toxic  principle,  or  of  a 
nervous  reflex. 

(i)  Theory  of  Metastasis  by  Mechanical  Irritation. — Sir 
W.  Roberts  does  not  hesitate  to  assume  a  precipitation 
of  uric  acid  in  the  visceral  situations  which  become  the 
seat  of  disturbance.  The  occurrence  of  visceral  seizures 
as  pre-arthritic  prodromata  undoubtedly  lends  support  to 
this  view,  the  blood  being  already  charged  with  uric  acid 
a  few  hours  before  the  attack,  the  gouty  dyscrasia  at  its 
height,  and  precipitation  imminent.  An  opposite  reason- 
ing applies,  however,  to  the  other  set  of  cases  where  the 
aifected  joint  has  already  relieved  the  blood  of  a  great 
deal  of  its  uric  acid  excess. 

Again,  on  the  theory  of  leucocytosis,  it  is  conceivable 
that  through  relatively  sudden  proliferation  and  destruc- 
tion of  leucocytes  the  uric  acid  production  might  be 
suddenly  raised ;  whilst,  conversely,  influences  rapidly 
modifying  the  leucocytosis  (physical  exertion,  alteratives, 
strong  mental  impressions)  might  abruptly  stop  or  lessen 
the  acute  articular  symptoms  ;  indeed,  some  extraordinary 
instances  have  been  recorded  in  which  a  single  dose  of  a 
remedy  such  as  morphia,  or  the  heroic  plan  of  warding  off 
the  attack  by  violent  exercise,  proved  absolutely  successful. 

There  is,  however,  a  wide  gap  between  the  recognition 
of  abrupt  fluctuations  in  the  amount  of  uric  acid  available 
for  precipitation,  and  a  demonstration  of  the  deposition 
in  the  viscera.  Of  this  occurrence  no  definite  proof  has 
hitherto  been  supplied. 


NATURE  AND  MECHANISM  OF  GOUTY  METASTASIS    269 

(2)  The  Theory  of  Metastasis  by  Toxic  Agency. — Short  of 
admitting  a  transference  of  the  biurate  from  the  uratic 
joint,  or  from  the  supersaturated  blood  to  the  viscus,  and 
a  mechanical  irritation  of  the  tissues  by  the  acicular 
deposit,  we  might  assume  that  toxic  principles  circulating 
in  the  blood  might  irritate  various  organs  in  the  order 
of  their  excitability.  Diabetic  coma  and  uraemia  are 
instances  in  point.  Although  the  symptoms  of  uraemia 
are  not  strictly  analogous  to  those  now  under  discussion, 
the  irregularities  in  the  excretion  of  urea  bear  some 
resemblance  to  those  affecting  uric  acid  in  gout ;  and  in 
both  instances  the  brain  is  apt  to  suffer,  although  in  gout 
this  is  the  exception,  and  in  uraemia  the  rule. 

Uraemia  has  received  special  attention  in  Professor 
Bouchard's  recent  studies  on  '  auto  -  intoxications.' 
Bouchard,  as  a  result  of  experiments  on  animals,  points 
out  that  urea  is  not  poisonous,  and  that  its  intravenous 
injection  into  rabbits  destroys  life  only  when  the  quantity 
of  urea  solution  injected  amounts  to  the  bulk  of  injection 
which  proves  fatal  even  when  pure  water  is  used.  He 
gives  reason  for  a  conclusion  that  in  uraemia  it  is  not  an 
excess  of  urea  in  the  blood  which  produces  the  symptoms, 
but  the  substitution  for  it  of  those  substances  which 
should  have  been  transformed  into  urea.  In  support  of 
this  view,  he  is  able  to  demonstrate  that  on  the  advent 
of  uraemia  the  normal  toxic  properties  of  healthy  urine 
are  lost  ;  urccmic  urine  is  no  longer  a  toxic  fluid. 

In  conclusion,  the  toxic  theory  is  hard  to  prove  or 
disprove.  Besides  uric  acid,  the  non-toxic  character  of 
which  has  already  been  pointed  out,  various  substances 
possibly  added  to  the  circulation  from  the  faulty  meta- 
bolism of  gout,  may  be  capable  of  toxic  actions  under, 
special  circumstances ;  but  of  all  this  we  know  nothing. 
The  instances  of  idiosyncrasy  show  that  the  smallness  of 


270    NA TURE  AND  MECHANISM  OF  GOUTY  METASTASIS 

the  dose  of  the  original  irritant  is  not  an  argument  against 
this  explanation ;  though  it  would  militate  against  the 
possibility  of  identifying  the  poison  or  of  proving  its 
aetiological  influence. 

(3)  The  Nervous  Reflex  Theory  of  Gouty  Metastasis  differs 
absolutely  from  the  more  materialistic  theories,  those  of 
precipitation  and  of  intoxication.  No  urate  of  sodium 
passes,  in  connection  with  the  events  of  retrocedent  gout, 
between  blood  or  joint  and  viscus,  but  the  sudden  check 
suffered  by  the  articular  inflammation  is  merely  re-echoed 
along  and  through  the  nervous  system  into  those  parts 
which  at  the  time  happen  to  be  most  susceptible,  therein 
setting  up  functional  changes. 

Looking  outside  the  domain  of  gout,  we  find  that,  with 
the  exception  of  the  embolic  affections,  migratory  symp- 
toms occurring  at  a  distance  from  the  source  of  irritation 
are  most  commonly  localized  in  the  viscera  by  nervous 
agency.  The  paroxysmal  heart  attacks  of  hurry  or  of 
diminished  rate  ;  the  phenomena  of  Graves's  disease  and 
of  pseudo-angina ;  the  gastric  crises  of  hysteria  and  those 
of  locomotor  ataxy ;  the  convulsions  of  infants  from 
indigestible  food ;  the  convulsive  seizures  of  children  at 
the  onset  of  febrile  disease,  and  expecially  of  the  exanthe- 
mata ;  the  functional  paralyses,  such  as  witnessed  in 
hysteria,  etc.  ;  the  hyperpnoea  accompanied  with  tachy- 
cardia, seen  in  some  cases  of  functional  exhaustion  of  the 
nervous  centres — these,  and  many  more,  are  instances  of 
deep  and  sudden  nervous  disturbances  connected  with 
peripheral  irritation. 

In  gout  itself  the  nervous  theory  of  metastasis  finds  the 
strongest  support  in  the  obviously  nervous  causation  of 
some  of  the  articular  attacks,  particularly  under  the  influ- 
ence of  excessive  cerebral  activity. 

The  mechanism  of  the  alleged  nervous  agenc}^  in  meta- 


THE   VASCULAR  REACTIONS  OF  GOUT  271 

stasis  is  presumably  vaso-motor,  the  immediate  cause  of 
the  symptoms  being  the  abrupt  alteration  induced  in  the 
visceral  circulation.  This  would  be  but  a  modification  of 
normal  functions.  The  fluctuations  between  peripheral 
and  visceral  circulation  are  often  manifested  in  everyday 
life.  In  pathology  vaso-motor  reflexes  hold  a  recognised 
place,  and  to  these  we  shall  now  turn  our  attention. 

THE   VASCULAR  REACTIONS  OF  GOUT. 

Whether,  as  contended  by  Sir  Spencer  Wells, "^  pre- 
dominant nervous  activity  is  a  distinct  predisposing  agent, 
or  whether  the  nervous  quickness  which  is  characteristic 
of  gout  arises  from  the  nutritional  conditions  which  breed 
the  disease,  it  is  sufficiently  obvious  that  the  vaso-motor 
events  are  rapid  and  extensive  in  the  cutaneous  and 
general  circulation  of  gouty  subjects. 

It  is  during  the  attack  itself  that  the  vascular  reactions 
acquire  an  almost  stormy  development.  The  initial  rigor, 
so  often  experienced,  is  the  first  foreboding  of  the  storm  ; 
and  it  is  noteworthy  that  this  is  a  general  symptom 
suggesting  strongly  the  implication  of  the  entire  vascular 
system,  as  a  storm  modifies  the  whole  atmosphere  over  a 
considerable  surface. 

In  connection  with  the  great  toe,  where  the  gout-storm 
so  often  breaks,  the  vascular  phenomena  are  most  striking. 
The  greatly  reddened  and  shiny  skin  and  the  abrupt 
oedema  indicate  intense  local  action.  Its  mechanism  is 
still  unknown,  but  that  it  is  worked  through  the  agency 
of  the  vascular  system  is  not  doubtful.  The  vessels  of  the 
part  are  turgid  ;  fluid  is  poured  out  into  the  tissues  as 
though  to  soak  them  and  wash  them  out,  and  perhaps 
serves  the  purpose  of  floating  the  scavenger  cells.     Mean- 

*  Loc.  cit.,  p.  26. 


272  THE   VASCULAR  REACTIONS  OF  GOUT 

while  in  other  parts  of  the  body  pressure  is  got  up  by 
vaso-constriction,  and  under  this  stimulus  the  heart  acts 
vigorously,  whilst  the  pressure  from  the  local  vaso- 
dilatation is  probably  the  cause  of  much  of  the  pain.  In 
the  general  cardio-vascular  excitement  we  have  the  indica- 
tion for  a  remedy  such  as  colchicum,  and  a  partial  expla- 
nation for  its  beneficial  action. 

The  HypercEinic  Processes  in  Visceral  and  in  Retrocedent 
Gout. — Hypersemia  is  probably  the  prevailing  feature  in 
visceral  gout.  In  the  alimentary  tract  the  congestive  form 
of  metastasis  is  that  with  which  we  are  most  familiar. 
We  find  it  in  the  liver,  spleen,  intestine,  and  stomach. 
Of  all  these  varieties,  metastatic  gouty  gastritis  is  the 
affection  most  often  described  and  most  dreaded.  Three 
modes  of  origin  have  been  assigned  to  it  :  {a)  The  local 
irritation  produced  on  the  mucous  membrane  by  an  ill- 
timed  and  an  ill-planned  meal ;  {b)  the  local  irritation 
attributed  to  a  local  deposition  of  biurate  crystals,  sup- 
posed to  take  place  in  its  walls ;  (c)  the  influence  of  a 
central  irritation  of  the  vagus  reflected  to  the  stomach. 
That  these  provocations  should  lead  to  congestion  is  a 
reasonable  inference.  Evidence  to  that  effect  is,  however, 
very  incomplete.  In  the  rare  instances  in  which  the 
post-mortem  appearances  of  the  stomach  after  metastatic 
gastritis  have  been  reported,  congestion  of  the  mucous 
membrane  has  been  observed. 

The  Ischcemic  Processes  in  Retrocedent  Gout.  —  Among 
visceral  and  retrocedent  attacks  there  are  probably  more  in- 
stances of  the  ischsemic  process,  and  in  the  visceral  mani- 
festations of  goutiness  there  is  probably  more  of  ischsemia, 
than  we  have  been  accustomed  to  suspect.  At  any  rate, 
the  tension  of  pulse  so  often  observed,  even  anterior  to 
any  kidney  disease,  suggests  peripheral  vaso-constriction. 
Among:  the  visceral  seizures  attributable  to  ischaemia,  none 


THE  VASCULAR  REACTIONS  OF  GOUT  273 

are  more  striking  than  some  of  the  functional  cerebral 
attacks  with  affection  of  speech  and  of  memory,  described 
under  gouty  encephalopathy.  These  are  clearly  to  be 
distinguished  from  the  apoplectiform  attacks  so  often 
recorded  in  connection  with  gout.  Congestion  is  the 
obvious  antecedent  of  the  haemorrhagic  seizures  ;  but  it 
does  not  supply  an  easy  explanation  for  the  symptoms  in 
question.  But  for  its  temporary  nature  and  complete 
recovery,  the  abrupt  loss  of  function  of  some  of  the  cortical 
centres  reminds  us  of  that  traced,  in  embolism,  to  the 
sudden  cessation  of  the  local  blood-supply.  It  suggests 
an  extreme  degree  of  local  ischaemia ;  but  a  demonstra- 
tion of  the  latter  has  never  been  given. 

The  metastatic  pseudo-anginal  seizures  elsewhere  de- 
scribed supply  us  with  equally  strong  inferences.  The 
vascular  factor  in  the  causation  of  the  true  anginal  attack 
is  not  congestion,  but  ischaemia,  and  if  variations  in  the 
arterial  calibre  take  any  active  share  in  the  gouty  meta- 
static anginoid  seizures,  they  must  lie  in  the  direction  of 
constriction  rather  than  of  dilatation. 

In  conclusion,  the  theory  of  mechanical  irritation  by 
migratory  deposits  of  sodium  biurate,  whilst  it  incurs  the 
onusprobandi,  inasmuch  as  the  assumptions  which  it  makes 
are  within  the  range  of  possible  demonstration,  remains 
destitute  of  anatomical  proof.  Even  a  discovery  of  uratic 
deposits  in  various  organs  would  not  in  itself  enable  us  to 
conclude  that  they  had  been  in  any  way  responsible  for 
the  visceral  seizures.  Moreover,  this  is  to  a  certain  extent 
an  hypothesis  ex  hypothesi.  So  long  as  strict  proof  is  want- 
ing that  gouty  arthritis  itself  is  the  result  and  not  the 
cause  of  the  precipitation  of  sodium  biurate,  the  '  showers 
of  urates  '  suggested  by  Sir  W.  Roberts  would  not  consti- 
tute, in  spite  of  their  captivating  simplicity,  any  definite 
proof. 


274  THE  VASCULAR  REACTIONS  OF  GOUT 

Assuming,  then,  that  the  visceral  changes  are  chiefl}^ 
vascular,  they  might  conceivably  be  caused  by  direct  toxic 
irritation,  or  through  nerve  agency  from  a  distance.  Both 
views  are  hypothetical,  though  not  equally  so :  we  are 
familiar  with  visceral  reflex  phenomena,  but  of  the  sup- 
posed toxic  agent  we  know  nothing.  Lastly  reflex 
ischsemise  and  hyperaemise  are  often  within  the  reach  of 
clinical  observation.  That  these  are  the  mechanisms 
most  commonly  at  work  in  metastatic  gout  is  rendered 
probable  by  the  rapidity  of  the  clinical  changes  observed, 
which  could  ill  be  explained  by  such  slow  processes  as 
those  dependent  upon  intracellular  metabolism. 


CHAPTER  XXXI. 

ON  SOME  OF  THE  CLINICAL  PECULIARITIES 
OF  GOUT  AND  GOUTINESS,  GOUTY 
INHERITANCE,  AND  GOUTY 
IDIOSYNCRASY. 

Under  this  heading  may  be  briefly  considered,  in  addi- 
tion to  the  individual  pecuHarities  of  gouty  subjects  in 
general,  those  of  certain  groups  of  subjects,  and  particu- 
larly of  the  female  sex  before  and  after  the  menopause. 
Again,  in  connection  with  gouty  symptoms,  attention  will 
be  called  to  the  well-known  tendency  to  a  paroxysmal 
and  nocturnal  onset. 

The  Relative  Immunity  of  the  Female  Sex. — Deep  signifi- 
cance attaches  to  the  fact  that  women  do  not  suffer  from 
gout  as  often  or  as  severely  as  men,  and  that  prior  to 
the  menopause  their  liability  is  very  slight.  Most  striking 
is  their  relative  immunity  from  articular  complications. 
Goutiness  expresses  the  usual  extent  of  their  ailment.  To 
all  gouty  nerve  manifestations,  including  glycosuria,  and 
to  those  minor  structural  changes,  such  as  nodules  on  the 
fingers,  etc.,  which  are  under  the  influence  of  the  nervous 
system,  they  are  distinctly  liable ;  but  declared  articular 
gout  is  with  them  the  exception.  This  marked  difference 
between  the  sexes  is  usually  explained  in  connection  with 
diet ;  but  the  influence  of  the  menopause  in  heightening 
the  gouty  liability  of  women  points  to  there  being  some 
other  modifying  factor  besides  their  habits  of  life. 


276  FEMALE  IMMUNITY 

The  adaptations  of  the  system  to  the  possibiHties  as 
well  as  to  the  actualities  of  maternal  life  are  largely  ques- 
tions '  beyond  our  philosophy,'  but  their  influence  must  be 
great  in  connection  with  nutrition.  During  the  sexual 
period  of  life  the  ever-recurring  cycle  of  ovarian  changes 
implies  something  more  than  a  periodical  emunction,  viz., 
a  perpetual  employment  of  energy  in  a  formative  direc- 
tion. The  fluctuations  in  this  expenditure  are  probably 
reflected  upon  the  metabolism  of  the  nervous  system  and 
of  the  economy,  and  might  exercise  upon  them  an  influence 
distantly  analogous  to  that  impressed  upon  nutrition  by 
systematic  variations  in  the  supplies. 

So  long  as  ovarian  life  is  active,  the  muscular  system 
takes  a  secondary  part ;  and,  as  a  general  rule,  animal 
food  is  less  desired  by  the  young  female  than  those  of  the 
carbo-hydrate  and  fatty  groups.  With  the  advent  of  the 
menopause  these  various  factors  no  longer  prevail,  and, 
whilst  the  liability  to  gout  remains  decidedly  less  than  in 
the  male,  the  balance  shows  a  tendency  to  be  restored. 

Idiosyncrasy  is  a  leading  characteristic  in  gout,  and 
whichever  form  it  may  take,  it  is  the  expression  of 
heightened  excitability  and  lowered  resistance  in  general, 
and  especially  of  the  nervous  mechanisms.  That  some 
persons  should  develop  gout  under  influences  which  to  the 
majority  are  harmless,  suggests  as  possible  an  original 
peculiarity  or  latent  idiosyncrasy  with  gout  as  its  result ; 
but  the  idiosyncrasies  bred  of  gout  are  more  obvious  and 
definite. 

Idiosyncrasies,  being  inborn,  belong  to  the  gout  which 
is  inherited  rather  than  to  that  which  is  acquired.  We 
have  already  dwelt  upon  some  of  their  forms  :  nervous 
asthma,  hay-fever,  and  other  respiratory  neuroses  are 
idiosyncrasies.  Instances  not  less  familiar  are  those  of  a 
disproportionate  reaction  upon  irritation  of  the  alimentary 


HEREDITARY  TRANSMISSION  277 

tract,  and  of  reflected  visceral  and  cerebral  disturbances. 
Again,  in  the  children  of  gouty  parents  the  skin  often 
affords  the  earliest  evidence  of  idiosyncrasy,  urticarial 
rashes  arising  from  ingesta  which  are  food  to  the  healthy 
subject,  but  poison  to  the  bearer  of  the  peculiarity.  A 
gouty  inheritance  is  often  at  the  root  of  the  extraordinary 
digestive  disabilities  met  with  in  practice.  The  disinclina- 
tion of  some  children  for  sweets,  of  others  for  animal 
food,  and  the  intolerance  of  some  infants  for  milk,  belong 
to  the  same  class. 

The  peculiarities  of  hereditary  transmission  are  no  less 
mysterious,  both  as  regards  uncertainty  in  its  incidence 
and  variation  in  its  form.  The  singular  alternations 
between  various  types  of  goutiness  sometimes  witnessed 
in  successive  generations  have  already  been  dwelt  upon. 
In  connection  with  this,  the  influence  of  atavism  is  not  to 
be  overlooked.     In  the  words  of  Hutchinson  :* 

'  We  deal  more  frequently  with  inherited  tendencies 
than  with  an  acquired  disease.  The  earlier  the  manifesta- 
tion, the  more  probably  are  they  due  mainly  to  inherit- 
ance. The  inheritance  of  gout  is  almost  always  modified 
by  the  inheritance  of  peculiarities  of  circulation,  entailing 
liability  to  chilblains,  cold  extremities,  and  the  like.  The 
inheritance  of  gouty  symptoms  combines  with  the  inherit- 
ance of  scrofula  also.  All  gouty  patients  are,  with  the 
rarest  exceptions,  more  or  less  rheumatic,  and  in  hereditary 
descent  the  tendency  to  rheumatism  and  to  gout  becomes 
inextricably  mixed.  Such  affections  as  sciatica,  lumbago, 
arthritis  of  small  joints,  and  crippling  affections  of  single 
large  joints,  may  be  trusted  to  a  very  considerable  extent 
as  implying  inheritance  from  gouty  ancestors. 'f 

*  Archives  of  Surgery,  July,  1895. 

t  In  this  connection  Mr.  Jonathan  Hutchinson  states  in  the  Archives 
of  Surgery  for  June,  1896,  p.  56  :  'The  association  between  inherited 


278  THE  NOCTURNAL  EVENTS  IN  GOUT 

'  The  arthritic  affections  which  are  due  to  acquired 
gout  are  usually  extremely  painful ;  but  those  due  to  an 
inherited  tendency  are  often  insidious  and  almost  pain- 
less.' 

The  peculiarities  in  the  march  of  the  disease  are  chiefly 
those  of  its  periodicity  and  of  the  paroxysmal  character  of 
its  manifestations. 

Various  explanations  have  been  offered  for  the  recurrence 
of  gout  at  definite  seasons  of  the  year ;  into  this  question 
we  need  not  enter  again.  There  is  some  analogy  between 
the  seasonal  periodicity  and  the  peculiar  preference  shown 
by  the  more  acute  gouty  manifestations  for  an  occurrence 
during  the  night,  and  to  this  subject  we  shall  devote  a 
few  concluding  remarks. 

THE  NOCTURNAL  EVENTS  IN  GOUT. 

A  remarkable  feature  in  the  histor}^  of  gouty  events  is 
their  preference  for  a  nocturnal  onset.  The  most  common 
nocturnal  trouble  is  insomnia,  and  its  peculiarities  are 
suggestive  of  the  kind  of  influence  which  may  govern  the 
whole  group.  Nothing  is  more  common  than  for  a  gouty 
person  to  be  suddenly  aroused,  after  a  sound  and  rather 
heavy  early  sleep,  by  some  internal  discomfort,  frequently 
connected  with  indigestion.  In  other  cases  the  awaken- 
ing remains  unexplained,  but  sleep  will  not  return  for  an 
hour  or  two,  or  longer. 

It  is  almost  precisely  at  the  same  time  of  night,  viz., 
about  two  o'clock,  that  the  gouty  asthmatic  wiH  begin  to 
sufl"er  from  his  dyspnoea,  the  gouty  bronchitic  from  his 
cough,  or  that  palpitation  or  angina  will  seize  upon  the 

gout  and  gonorrhoeal  rheumatism  is  one  respecting  which  I  have  long 
entertained  no  doubt  whatever.  Of  late  years  I  have  never  seen  gouty 
rheumatism  without  obtaining  the  history  of  gout  in  the  family.' 


THE  NOCTURNAL  EVENTS  IN  GOUT  279 

patient  with  a  neurotic  heart.  Again,  wandering  fibro- 
muscular  pains,  stiffness,  cramp,  neuralgia,  and  a  host  of 
troubles,  will  now  make  their  beginning ;  or  there  may  be 
irritability  of  the  skin.  Lastly,  it  is  about  this  time  that 
the  acute  arthritic  attack  will  suddenly  break  upon  the 
scene. 

The  uniformity  in  the  time  of  onset  of  many  of  the 
gouty  manifestations,  and  of  those  more  purely  neurotic, 
furnishes  an  argument  for  the  view  that  gout  itself  is  a 
neurosis.  We  cannot  place  much  reliance  upon  evidence 
of  this  kind  so  long  as  the  mechanism  of  the  nocturnal 
neurotic  seizures  remains  a  mystery. 

An  important  step  towards  the  elucidation  of  this 
broader  question  has  been  made  by  Bouchard  in  his  re- 
searches on  the  relative  toxicity  of  the  urine  secreted  at 
different  periods  during  the  twenty-four  hours.*  His 
conclusions  relate  to  the  varying  quantity  and  to  the 
varying  quality  of  the  toxic  matter  excreted. t  The  urine 
of  the  night  has  been  found  experimentally  to  be  decidedly 
less  toxic  (in  the  proportion  of  i  to  2,  or  i  to  4),  although 
in  other  respects  more  concentrated  than  that  of  the  day 
— a  circumstance  suggesting  at  any  rate  a  lessened  in- 
tensity of  toxic  elimination  during  the  night,  though  not 
affording  any  evidence  as  to  the  relative  intensity  of  toxic 
production  ;  but  it  possesses  the  toxic  properties  of  a  con- 
vulsant,  whereas  that  of  the  day  is  narcotic. 

The  liability  to  nocturnal  spasmodic  affections  might 
conceivably  be  connected  with  some  disturbance  between 

*  Bouchard,  '  Lectures  on  Auto-intoxication  in  Disease,'  etc.  ;  trans- 
lated by  Thomas  OHver,  M.A.,  M.D.,  F.R.C.P.,  etc.  Philadelphia: 
F.  A.  Davis  Co.  ;  London  :  E.  J.  Rebman,  1894. 

t  '  The  toxic  principles  excreted  by  a  man's  kidney  in  fifty-two  hours, 
on  an  average,  would  suffice  to  produce  in  him  fatal  intoxication '  {/oc. 
cit.,  p.  35). 


28o  THE  NOCTURNAL  EVENTS  IN  GOUT 

the  normal  proportions  of  the  two  sets  of  poisons — for 
they  have  been  shown  by  Bouchard  to  be  mutual  anti- 
dotes— or  with  a  disturbed  relation  between  the  produc- 
tion and  the  excretion  of  the  nocturnal  convulsing 
principles. 

Much  light  is  also  thrown  on  the  question  by  the  obser- 
vation that  the  total  toxicity  of  urine  is  diminished  by 
muscular  exercise — that  is,  by  increased  oxidation — not 
only  during  the  day  of  the  exertion,  but  during  the  ensuing 
night. 

The  onset  of  symptoms  in  the  small  hours  of  the  night 
might  be  accounted  for  somewhat  in  this  way.  The  nar- 
cotic principles  due  to  the  diurnal  activity  of  the  organism 
might  suffice  to  secure  sleep  for  two  or  three  hours  only, 
but  prove  unequal  to  overcoming  the  undue  influence  of 
the  nocturnal  principles,  whether  the  latter  had  been  pro- 
duced in  excess  or  had  been  imperfectly  eliminated  into 
the  urine. 

The  explanation  suggested  is  merely  hypothetical.  It 
has,  however,  the  merit  of  suggesting  for  the  explanation 
of  the  uniformity  observed  in  the  clinical  facts  the  opera- 
tion of  some  general  and  uniform  physiological  process. 

In  connection  with  the  physiological  functions,  much 
may  be  explained  by  habit  alone.  Habit  may,  in  this 
instance,  assist  in  bringing  about  the  early  sleep,  in  spite 
of  some  disturbance  already  at  work.  In  children,  usually 
heavy  sleepers,  not  only  is  this  early  rest  obtained,  but 
often  enough  the  various  spasmodic  affections  may  be 
seen  to  occur  without  the  spell  of  sleep  being  broken.  In 
the  adult  also,  physiological  habit  might  tend  to  delay  the 
trouble  till  after  the  first  sleep. 

Again,  the  time  of  the  nocturnal  events  may  be  deter- 
mined in  connection  with  some  other  physiological  cycles, 
such  as  that  of  body  temperature  or  of  digestion.  Bouchard 


THE  NOCTURNAL  EVENTS  IN  GOUT  281 

himself  admits  that  '  the  toxicity  of  normal  urines  varies 
according  to  numerous  circumstances — cerebral  activity, 
muscular  activity,  sleep,  diet,  etc.'* 

Speculations  such  as  these  may  at  least  serve  to  show 
that  any  effort  to  identify  gout  with  the  neuroses  cannot 
safely  be  based  upon  the  mere  frequency  of  the  nocturnal 
manifestations  common  to  both.  They  would  rather 
suggest  the  view  which  has  considerable  support  in  other 
directions,  that  the  so-called  neuroses  are,  like  gout  itself, 
connected  with,  if  not  dependent  upon,  faulty  chemistry, 
and  upon  aufotoxis,  whether  by  hyperproduction  or  by 
retention. 

*  Loc.  a'f.,  p.  35- 


VII. 
GENERAL  CONCLUSIONS. 


CHAPTER  XXXII. 

CONCLUSIONS  BEARING  UPON  THE  URIC 
ACID  AND   RENAL  THEORY. 

The  preceding  pages  convey  some  imperfect  idea  of  the 
extent  of  the  subject.  Far  from  being  explained,  the 
problem  of  gout  seems  to  have  grown  with  each  successive 
effort  to  solve  it.  New  theories  are  less  wanted  than  a 
weeding  out  of  some  of  the  older  ones.  We  should  build 
upon  well-ascertained  facts  only,  and  be  content  at  first  to 
ascertain,  if  possible,  what  gout  is  not,  leaving  it  for  the 
future  to  show  what  gout  is. 

Gout  might  be  made  too  exclusively  a  '  renal,'  or  a 
'  hepatic,'  or  a  '  nervous  '  question.  Whilst  in  these  pages 
we  consider  these  three  aspects  separately  for  the  sake  of 
clearness,  we  shall  endeavour  to  prove  that  they  are  in 
reality  inseparable. 

Our  available  materials  concerning  uric  acid  may  be 
summed  up  in  a  few  propositions  : 

I.  Uric  acid  being  very  readily  excreted  by  the  kidney, 
over-production  of  uric  acid  in  the  otherwise  healthy 
system  is  generally  manifested  by  an  increased  output  in 
the  urine.  This  method  of  estimating,  by  means  of  the 
amount  detected  in  the  urine,  the  amount  produced  in  the 
system  is  trustworthy  in  most  instances. 


THE  URIC  ACID  AND  RENAL  THEORY  283 

2.  To  this  rule  gout  forms  an  exception.  During  the 
attack  of  gout,  as  shown  by  Sir  A.  Garrod,  the  amount 
present  in  the  blood  is  increased,  but  the  urine  contains 
less  than  the  average  ;  whilst  in  various  other  morbid 
states,  but  especially  in  leucocythsemia  and  in  pneumonia, 
the  blood  being  charged  with  uric  acid,  the  urine  contains 
an  excess  of  it  also. 

3.  The  incomplete  excretion  of  the  uric  acid  of  the 
blood  by  the  kidney  is  a  peculiarity  of  gout. 

4.  Another  peculiarity  of  gout  is  the  deposition  of  part 
of  the  excess  present  in  the  blood  into  the  joints  and 
fibrous  tissues.  This  does  not  take  place  in  the  other 
instances  of  uricacidaemia. 

5.  Gout  is  further  characterized  b}-  an  habitually  low 
percentage  of  uric  acid  in  the  urine  ;  whilst,  during  the 
intervals  between  the  attacks,  the  blood  may  contain  onl}' 
a  very  slight  or  vanishing  amount. 

6.  The  distinctive  feature  of  gout  is  not  so  much  the 
over-production  of  uric  acid,  which  probably  never  equals 
that  observed  in  leucocythgemia,  as  its  defective  elimina- 
tion. Since,  as  originally  pointed  out  by  Garrod,  there 
may  be  in  some  cases  of  gout  no  excess  in  the  produc- 
tion, the  latter  even  remaining  below  the  average,  the 
fault  is  then  entirely  retention. 

7.  The  cause  and  the  mechanism  of  the  defect  are  not 
thoroughly  understood.  The  assumption  that  it  is  a  renal 
defect  has  been  based  upon  the  fact  that  kidney  diseases, 
independently  of  gout,  lead  to  an  excess  of  uric  acid  in  the 
blood.'^ 

*  Von  Jacksch,  in  a  series  of  twelve  cases  of  kidney  disease,  found 
uricacidaemia  in  nine,  four  being  cases  of  acute,  two  of  chronic,  one 
of  lardaceous,  and  two  of  granular  atrophic  nephritis.  The  largest 
amounts  of  uric  acid  were  found  in  the  cases  of  renal  cirrhosis  and 
incipient  urtemia  (Levison,  /oc.  a'f.,  p.  55). 


284  THE  URIC  ACID  AND  RENAL  THEORY 

8.  Some  weight  belongs  also  to  the  observation  that 
poisons  such  as  alcohol  and  lead,  which  favour  the  develop- 
ment of  gout,  also  damage  the  kidney,  the  toxic  lesions 
presenting  singularly  close  resemblance  with  those  arising 
as  a  result  of  gout  itself. 

g.  The  frequency  of  saturnine  gout  was  first  pointed  out 
by  Garrod  in  1854,  and  has  been  confirmed  by  many 
observers.  Lancereaux*  found  seven  cases  of  gout  among 
twenty-four  cases  of  lead  intoxication.  This  frequency 
possesses  significance  in  connection  with  the  regularity 
with  which  lead  affects  the  kidney. 

10.  Clinical  observation  and  experiments  in  animals 
show  that  lead  almost  invariably  affects  the  kidney 
(c/.  p.  173).  Garrod  has  further  shown  that  uric  acid  can 
be  detected  in  the  blood  of  sufferers  from  lead,  even  when 
free  from  any  gout ;  and  that,  moreover,  the  amount  of 
uric  acid  excreted  in  the  urine  may  be  reduced  by  the 
administration  of  even  moderate  doses  of  the  pharma- 
copceial  preparations  of  lead. 

11.  These  facts  strongly  favour  the  view  that  the  gouty 
accumulation  of  uric  acid  is  due  to  some  renal  defect ;  but 
the  following  observations  greatly  reduce  their  force. 

12.  Complete  parallelism  does  not  invariably  obtain 
between  the  liability  of  the  kidney  and  that  of  the  joints. 
Though  the  kidney  always  suffers,  the  joints  are  not 
always  affected.  Nay ;  Christison  pomted  out  that  in 
Scotland,  where  gout  was  almost  unknown,  it  was  not 
observed  even  among  workers  in  lead,  and  that  in 
Edinburgh  saturnine  gout  practically  did  not  exist.  This 
is    also   the    experience   of    Professor    Philipson    and   of 

*  '  Nephrite  et  Arthrite  saturnine '  {Archives  General  de  Medicitie, 
December,  1881).  See  also  Rendu's  account  of  this  subject,  giving 
references  to  Charcot,  OlHvier,  Potain,  Bucquoy,  Lancereaux,  etc. 
{Did.  Eticycl.  des  Sc.  Me'dicales,  1884,  art.  '  Goutte,'  pp.  184-187). 


THE   URIC  ACID  AND  RENAL  THEORY  285 

Dr.  T.  Oliver  in  Newcastle,  where  spirits  are  habitually 
consumed,  in  preference  to  beer,  by  the  working  classes. 
Rendu*  likewise  refers  to  saturnine  gout  as  being  much 
less  prevalent  in  France  and  in  Germany  than  in  England. 
He,  however,  also  draws  attention  to  the  fact  that  French 
observers  (i)  have  not  always  found  uric  acid  in  the  blood 
of  saturnine  gout  (Bucquoy  and  Halma),  or  even  of  gout 
itself;  (2)  nor  always  found  in  lead  intoxication  a  diminished 
elimination  of  uric  acid  and  of  urea,  but  sometimes  the 
reverse  (Gubler  and  Albert  Robin)  ;  (3)  nor,  lastly,  did 
they  find  in  every  case  of  ordinary  gout  a  decrease  in 
these  excretions — indeed,  Bouchard  and  Lecorche  have 
frequently  found  an  increase. 

Discussion  is  paralyzed  by  these  contradictions  between 
authorities,  in  respect  of  the  clinical  and  experimental 
evidence  as  to  the  relative  amount  of  the  uric  acid 
excreted. 

13.  The  great  clinical  fact  observed  by  Christison 
stands,  nevertheless,  above  controversy.  Lead,  per  se,  does 
not  produce  gout. 

14.  Christison's  observations  contain  another  negative 
conclusion  of  still  greater  importance  :  any  original  kidney 
defect  due  to  lead,  and  any  saturnine  uricacidsemia,  are 
not  in  themselves  capable  of  inducing  gout. 

15.  It  also  contains  a  positive  conclusion  of  great  value. 
The  gout  of  lead-workers  is  brought  about  by  some  agency 
which  is  not  renal,  however  much  renal  defect  may  add 
to  the  result. 

16.  Clear  evidence  of  a  renal  lesion  preceding  the 
arthritis,  such  as  is  obtained  in  some  cases  of  saturnine 
gout,  would  lend  great  probability  to  Garrod's  uric  acid 
and  renal  theory.  A  practical  difficulty  arises  from  the 
fact  that  the  kidneys  in  early  gout  are  not  often  available 

*  Loc.  cit,  p.  186. 


286  THE  URIC  ACID  AND  RENAL  THEORY 

for  examination.  Garrod  has  shown,  however,  that  one 
or  two  attacks  of  acute  gout  may  suffice  to  determine 
in  them  visible  changes.  The  earhest  changes  in  the 
renal  epithelium  are  not  to  be  recognised  by  the  naked 
eye,  and  it  is  conceivable  that  kidneys  reported  as  healthy 
may  have  been  sufficiently  damaged  in  their  most  delicate 
and  essential  structure  to  render  them  unfit  for  perfect 
work.  Another  view,  previously  hinted  at  by  Sir  A. 
Garrod,  is  that  the  earliest  renal  trouble  may  be  a  purely 
functional  one,  not  destroying  the  power  of  secretion, 
but  merely  limiting  it  to  the  disposal  of  more  soluble 
constituents.  Charcot's  observations  bearing  on  this 
possibility  have  already  been  quoted.* 

17.  A  temporary  renal  inadequacy  might  thus  explain 
the  early  attacks  as  well  as  the  often  long  interval  before 
their  return.  A  subsequent  structural  change  would 
explain  both  the  increased  frequency  of  the  attacks,  and 
their  occurrence  on  much  slighter  provocation,  in  spite 
of  treatment,  and  concurrently  with  a  reduction  in  the 
production  of  uric  acid  below  the  healthy  average — condi- 
tions strongly  contrasting  with  the  early  attacks,  which 
need  great  provocation,  and  a  large  increase  in  the 
uricacidsemia. 

The  same  views  would  be  supported  by  the  observation 
that  in  saturnine  gout,  which  is  admittedly  associated 
with  previously  established  renal  lesions,  the  gouty  attacks 
are  from  the  first  subacute  in  type,  and  resemble  the 
chronic  rather  than  the  acute  phase  of  the  disease  both 
in  the  multiplicity  of  the  joints  affected,  and  in  the  indo- 
lent nature  of  their  swelhngs. 

18.  Various  theories,  themselves  destitute  of  any 
absolute  evidence,  have  been  raised  in  opposition  to  the 
renal  theory.     One  of  them  only  need  be  mentioned. 

*  C/.p.  40. 


THE  RENAL  THEORY  QUESTIONED  287 

The  theory  of  over-production  is  patronized  by  Ebstein, 
who  insists  that  the  kidney  in  early  gout  need  present 
no  abnormahty  except  in  a  Hmited  class — that  of  primary 
renal  gout  with  granular  atrophy  ;  but  that  the  uric  acid 
in  the  blood  suffers  considerable  increase  as  a  result  of 
certain  tissues  having  assumed  in  its  formation  a  share 
which  does  not  normally  belong  to  them. 


THE  RENAL  THEORY  QUESTIONED. 

The  natural  tendency,  when  some  urinary  constituent 
behaves  in  an  abnormal  fashion,  is  to  connect  the  disease 
with  the  kidneys.  Sugar  escaping  in  diabetes  was  thought 
to  be  the  result  of  a  renal  disease.  The  failure  of  uric 
acid  to  be  excreted  in  a  normal  quantity  is  attributed  to 
renal  impermeability.  The  foundation  of  these  inferences 
is  not  in  either  case  a  strong  one.  Retention  of  uric 
acid  might  have  as  little  to  do  with  the  kidney  as 
glycosuria  itself. 

The  Nature  of  the  Renal  Block. — The  great  fall  in  the 
uric  acid  excretion,  described  by  Garrod  as  characteristic 
of  the  onset  of  the  acute  attack,  quickly  makes  way  for 
a  rise,  sometimes  to  a  higher  standard  than  in  health. 
What  are  we  to  think  of  so  transitory  a  change  ?  If 
organic,  the  lesion  must  be  of  the  slightest  kind,  perhaps 
comparable  to  the  changes  taking  place  within  a  few 
hours  in  an  abortive  coryza,  which  are  definite  in  them- 
selves and  in  their  results  as  affecting  secretion  yet  largely 
made  up  of  a  functional  neuro-vascular  disturbance. 
Such  a  process  as  this  might  be  superadded  to  a  more 
serious  and  chronic  lesion,  or  might  occur  in  a  perfectly 
healthy  kidney. 

Or  shall  we  regard  the  ephemeral  inhibition  of  the 
excretion  as  produced  in  some  other  way  and  independently 


THE  RENAL  THEORY  QUESTIONED 


of  the  kidney  ?  A  great  variety  of  circumstances  influence 
the  production  of  uric  acid,  as  shown  by  Horbaczewski, 
and  its  excretion,  as  shown  by  Sir  W.  Roberts.  The 
excretion  of  uric  acid  oscillates  even  in  health  with  remark- 
able ease  and  rapidity  on  the  slightest  provocation.  Is 
the  more  regular  and  significant  oscillation  connected 
with  a  gouty  attack  to  be  regarded  as  anything  more 
than  an  accentuation  of  the  every-day  oscillations  to 
which  much  less  importance  is  attached  ? 

By  the  side  of  the  assumed  renal  imperviousness  for 
uric  acid  in  gout  there  are  other  possibilities.  A  tophus 
is  built  up  by  progressive  depositions  of  biurate :  the 
presence  of  crystals  is  an  inducement  for  further  crystal- 
lization ;  but  the  original  inducement,  that  which  led  to 
the  first  deposit,  was  of  a  different  kind.  Was  it  mainly 
a  local  attraction  of  the  tissue  for  uric  acid  ?  Some 
authorities  {e.g.,  Ebstein)  would  consider  that  it  was. 
Indeed,  apart  from  gout,  certain  glands  or  organs  are 
credited  with  a  power  to  store  up  uric  acid.  Similar 
attractions  might  conceivably  be  exerted  at  times  by 
other  organs,  by  the  system  at  large,  or  by  the  blood. 

The  conditions  under  which  uric  acid  is  contained  in 
the  blood  of  the  gouty  have  not  been  accurately  defined. 
What  phases  uric  acid  may  undergo  even  in  health)^ 
blood  we  cannot  pretend  to  know,  but  Sir  A.  Garrod 
has  himself  pointed  out  that  it  is  prone  to  undergo 
change,  and  Salomon  was  able  to  detect  uric  acid  in 
perfectly  fresh  blood,  but  not  after  this  had  stood.  It 
is  not  then  more  difficult  to  imagine  a  temporary  rise  in 
the  uric  acid  retaining  power  or  modifying  power  of  the 
blood  and  of  the  tissues  than  a  transient  depression  of 
the  uric  acid  excreting  power  of  the  kidney. 

However  this  may  be,  there  is  another  and  more  definite 
aspect  of  the  renal  question,  that  which  is  connected  with 


THE  ARTICULAR  CHANGES 


the  secondary  kidney  changes,  viz.,  with  the  late  results 
of  gout  rather  than  with  its  alleged  kidney  -  derived 
aetiology. 

THE  ARTICULAR  CHANGES. 

The  Deposition  of  the  Biurate. — The  vicissitudes  of  the 
uric  acid  accumulated  in  the  blood,  and  the  chemical 
mechanism  of  its  precipitation,  have  been  clearly  set  forth 
by  Sir  W.  Roberts.  We  must  refer  the  reader  for  a  detailed 
account  of  these  events  to  previous  chapters  dealing  with 
the  chemistry  of  gout. 

The  articular  changes,  according  to  the  uric  acid  theory, 
present  two  phases  :  i.  The  stage  of  infiltration  ;  2.  The 
stage  of  inflammatory  reaction.  This  is  analogous  to  the 
reaction  set  up  by  a  foreign  body,  but  in  this  case  there  is 
often  a  relatively  long  period  of  tolerance. 

The  extreme  changes  now  taking  place  are  :  Nutritive 
alterations  in  the  cartilage  and  the  synovia ;  irritative  pro- 
liferation within  the  cells,  and  ultimate  destruction. 

The  question  as  to  whether  the  deposit  is  primarily 
within  the  cells  or  within  the  matrix  has  been  variously 
answered,  and  is  still  under  discussion. 


19 


CHAPTER  XXXIII. 

MATERIALS  TOWARDS  A  TROPHIC  THEORY.— 
GOUT,  GOUTINESS,  AND  THE  LIVER. 

The  theory  just  reviewed  starts  from  the  excess  of  uric 
acid,  which  it  accepts  as  d.fait  accompli,  and  proceeds  to 
study  the  mechanism,  and  the  results  of  its  precipitation. 
Those  to  which  we  now  turn  deal  mainly  with  gout  and 
goutiness  considered  as  the  source  of  the  uric  acid  excess. 
They  are  concerned  with  the  origins  of  gout. 

General  Features  of  Gout. — Not  limited  to  any  race,  but 
excessively  prevalent  in  some  ;  not  localized  in  any  climate, 
but  distinctly  rare  in  the  low  latitudes ;  not  the  exclusive 
outcome  of  any  form  of  diet,  but  unmistakably  influenced 
by  some  diets  for  good  and  by  others  for  evil ;  rare  in 
childhood,  and  uncommon  in  women,  especially  before 
the  menopause  ;  common  in  middle-aged  men,  and  ap- 
pearing earliest  when  inherited — gout  is  perhaps  the  most 
transmissible  of  morbid  peculiarities,  and  among  diseases 
it  would  seem  to  be  that  which  least  departs  from  the 
normal  type  of  life  and  growth.  Although  most  commonl}- 
inherited,  gout  is  also  frequently  acquired. 

The  general  conditions  favouring  its  development  are 
well  known ;  but  as  the  tendency  of  some  constitutions 
is  not  towards  gout,  it  may  be  doubted  whether  in  all 
individuals  the  affection  could  be  produced  at  will,  even 
by  a  most  perverse  application  to  the  task.     Dr.  Haig, 


CELLULAR  ACTIVITIES  IN  CONNECTION  WITH  GOUT  291 

however,  is  of  opinion  that  any  person,  by  using  the 
special  means  to  that  end,  might  be  made  to  suffer  from 
uratic  arthritis.  At  any  rate,  habitual  excessive  indul- 
gence in  eating  and  drinking  without  compensating 
exercise  is  the  recognised  cause  of  acquired  gout.  This 
suggests  that  we  should  look  to  the  organs  of  digestion 
for  the  key  to  its  pathology. 


THE    CELLULAR    ACTIVITIES    IN    CONNECTION    WITH 

GOUT. 

The  part  played  by  individual  cells  is  still  unknown, 
yet  it  is  to  them  ultimately  that  we  must  appeal  for  the 
desired  explanation.  A  simple  study  of  the  material 
absorbed  from  the  alimentary  canal  shows  that  it  consists 
of  undissolved  particles  floating  in  a  watery  solution. 
Were  this  fluid  to  be  kept  circulating  through  the  vessels 
only,  no  nutritive  purpose  would  be  effected,  however  rich 
in  nutriment  the  fluid  might  be ;  and  the  same  remark 
applies  to  blood  plasma.  They  must  be  absorbed  and 
digested,  by  living  cells.  Undissolved  nutritious  particles 
might  float  for  ever  unused  were  it  not  for  cell  agency. 

The  digestive  function  of  individual  cells  begins  with 
the  leucocytes.  If,  as  described  by  some  observers,  it 
is  their  duty  to  extend  their  pseudopodia  between  the 
basal  cells  lining  the  surface  of  the  villus,  and  to  capture 
passing  molecules,  and  when  fully  charged  with  these  to 
return  towards  the  interior  of  the  villus,  and  thence  make 
their  way  into  the  lacteals,  the  stress  which  must  be 
thrown  upon  them  in  cases  of  habitual  over-feeding  is 
obvious.  This  is,  however,  but  an  instance  of  similar 
difficulties  experienced  by  all  other  cells,  and  specially 
by  the  cells  of  the  glands  engaged  in  the  metabolism 
of  food. 


292  THE  LIVER  AS  ONE  OF  THE  DIGESTIVE  GLANDS 

THE  LIVER  AS  ONE  OF  THE  DIGESTIVE  GLANDS. 

With  the  laity,  and  often  with  the  profession  in  their 
relation  with  patients,  '  the  liver '  is  a  generic  expression 
loosely  applied  to  the  function  of  the  whole  alimentary 
system.  There  is  great  practical  truth  in  this.  In  con- 
nection with  digestion,  the  liver  plays  a  part  second  only 
in  time,  not  in  importance,  to  that  of  the  stomach  and 
duodenum.  The  liver  exercises  a  direct  influence  over 
the  lower  alimentary  tract,  and  an  indirect  one  over  the 
stomach,  pancreas,  spleen,  and  lacteals ;  the  various 
functions  may  thus  be  modified  for  better  or  for  worse 
through  its  agency. 

On  the  other  hand,  the  liver  is  dependent  upon  all  of 
them  for  its  raw  material,  the  quantity  and  quality  of 
which  must  influence  the  quality  of  the  hepatic  produce. 
Thus  we  might  easily  be  misled  into  taxing  the  liver  with 
sins  which  are  not  its  own.  Many  a  so-called  'liver 
attack '  is  really  acute  gastric  indigestion. 

This  use  of  the  word  '  liver  '  in  an  extended  sense  has 
not  detracted  in  the  past  from  the  independent  considera- 
tion claimed  by  the  stomach ;  but  due  attention  has  not 
always  been  bestowed  upon  the  spleen,  the  pancreas,  and 
the  intestine  in  their  connection  with  gout.  In  rousing 
us  to  a  consciousness  of  this  neglect.  Dr.  Mortimer 
Granville  has  done  good  service.  Whether  pancreatico- 
duodenal indigestion  has  really  any  setiological  influence 
in  gout  is  open  to  considerable  doubt.  That  it  should  be 
set  up  easily,  and  often  in  those  whose  diet  is  habitually 
imprudent,  is  that  which  we  have  long  known,  though  too 
often  overlooked.  This  condition  would  naturall}^  coincide 
at  times,  in  luxurious  eaters,  with  the  prodromata  of  gout, 
without  thereby  establishing  any  definite  aetiology. 

In   respect  of  bulk  and  of  variety,   the  raw  material 


THE  LIVER  AS  A  BLOOD-ELABORATOR  293 

absorbed  from  the  intestine  can  compare  with  that 
derived  from  the  stomach  and  duodenum.  Yet  httle  has 
hitherto  been  said  concerning  it.  The  spleen,  again, 
must  be  engaged  in  work  of  the  utmost  importance  to 
the  hepatic  function. 

From  any  of  these  sources  the  Kver  may  experience 
disappointments,  or  even  irritations,  and  much  of  its  evil 
reputation  in  gout  may  have  been  acquired  vicariously. 


THE  LIVER  AS  A  BLOOD-ELABORATOR. 

It  is  in  relation  to  the  composition  of  the  blood  that 
the  importance  of  the  liver  as  a  factor  in  nutrition  becomes 
apparent.  An  important  part  of  the  nutritive  albuminous 
fluids  of  alkaline  reaction  bathing  the  villous  tract  of  the 
small  intestine,  and  nearly  the  totality  of  the  fats,  in  a 
fine  state  of  subdivision,  are  taken  up  directly  into  the 
lacteals,  and,  passing  through  the  bodies  of  leucocytes 
and  of  lymphatic  cells,  are  poured  straight  into  the  blood. 
With  an  elaboration  of  this  portion  of  our  supplies  the 
liver  is  not  immediately  concerned.  Any  toxic  impurity 
thus  directly  absorbed,  or  subsequently  developed,  can 
only  be  fractionally  removed  by  the  liver  during  subsequent 
rounds  of  the  circulation,  and  would  doubtless  help  to 
keep  up  the  toxic  average  of  the  blood. 

The  rest  of  the  process  of  absorption  is  carried  on 
through  the  radicals  of  the  portal  vein ;  and  in  what  does 
it  consist  ?  A  large  quantity  of  fluid  charged  with  pep- 
tones, with  carbo-hydrates,  with  ferments,  with  pigments, 
and  with  salts,  and  with  soluble  toxic  principles,  whether 
introduced  or  manufactured  in  the  digestive  tract — with 
all  these  the  liver  has  to  deal.  But,  meanwhile,  it  is 
receiving  from  the  digestive  glands  venous  blood  im- 
poverished by  secreting  activity,  a  welcome  diluent  for 


294  THE  LIVER  AS  A  BLOOD^^ELABORATOR 

the  somewhat  acrid  nutritive  juices  in  transit.  From  all 
these  elements  pure  average  blood,  for  which  contact  with 
oxygen  at  the  lungs  is  to  be  the  finishing  touch,  has  to 
be  made  up  again  by  the  complex  hepatic  metabolism. 
The  proportion  in  which  effete  or  damaged  blood-cells  are 
broken  up  and  disposed  of  is  no  less  important  a  matter 
than  the  due  performance  of  the  three  great  metabolic 
functions  for  albumens,  carbo-hydrates,  and  hydro-car- 
bons, and  than  the  separation  of  the  nitrogenous  surplus 
and  the  fixation  or  oxidation  of  poisons,  whether  animal 
or  mineral. 

This  many-sided  activity  of  the  liver  as  an  elaborator 
of  common  food  into  cell-food,  as  a  manufacturer  of 
ferments,  as  a  purifier  and  refiner  of  the  blood,  in  addition 
to  its  intestinal  digestive  functions  proper,  places  it  at 
the  head  of  all  organs  subservient  to  nutrition.  No 
nutritive  process  of  any  importance  can  proceed  in  which 
it  has  not  some  share,  nor  can  nutrition  prosper  if  it  be 
overtaxed  or  paralyzed. 

THE  LIVER  IN  RELATION  TO  URIC  ACID. 

We  have  already  dwelt  upon  Murchison's  views  as  to 
the  production  of  lithsemia  by  functional  inadequacy  or 
disturbance  of  the  liver,  considered  not  only  as  the  source 
of  bile,  but  as  a  most  active  centre  of  metabolism.  Mur- 
chison  did  not  hesitate  to  trace  also  to  the  liver  the  faulty 
metabolism,  and  by  implication  the  excess  of  uric  acid 
peculiar  to  gout.  We  can  no  longer  subscribe  to  the 
opinion  that  the  liver  is  the  only  agent  in  uricacidaemia. 
There  is  strong  evidence  that  the  production  of  uric  acid, 
both  in  normal  and  pathological  states,  does  not  belong 
exclusively  to  the  liver,  that  the  spleen  takes  a  large  share 
in  it,  and  that  some  of  the  uric  acid  may  own  an  even 
wider  derivation  from  glands  and  tissues. 


LITH^EMIA  AND  GOUT  295 

In  favour  of  the  same  conclusion,  Rendu  points  out  that 
many  gouty  subjects  do  not  manifest  hepatic  complica- 
tions, and  that  severe  hepatic  disease  is  most  commonly 
unassociated  with  any  gouty  manifestations.  It  is  also 
remarkable  that  in  tophaceous  gout,  where  most  uric  acid 
is  deposited,  the  hepatic  manifestations  are  very  fre- 
quently absent.  According  to  Rendu,  uric  acid,  as  well 
as  urea  and  carbon  dioxide,  are  formed  wherever  nitro- 
genous tissues  are  undergoing  combustion. 


LITHMMIA  AND  GOUT. 

Nevertheless,  it  cannot  be  denied  that  between  lithsemia, 
as  understood  by  Murchison,  and  various  gouty  states,  a 
close  kinship  exists.  Heaviness,  depression,  torpor,  giddi- 
ness, headache,  insomnia,  gastro  -  intestinal  disturbance, 
varicose  veins,  haemorrhoids,  etc.,  which  belong  to 
lithsemia,  occur  also  in  many  cases  of  gout. 

The  lithuria  of  hepatic  engorgement,  or  of  lithsemia, 
has  its  analogy  in  the  lithiasis  or  gravel,  so  familiar  to  us 
in  the  gouty  or  their  descendants.  The  association  with 
gout  is,  however,  seldom  immediate.  Commonly  gout  and 
gravel  occur  in  separate  subjects  as  an  alternating  inheri- 
tance ;  or,  if  in  the  clinical  history  of  the  same  individual, 
at  wide  intervals  of  time.  We  need  not  here  point  out 
the  differences  in  the  urology  of  the  lithsemic  lithuria  and 
of  the  gouty  lithiasis :  the  excessive  pigmentation  of  the 
urine  in  the  one,  its  relative  pallor  in  the  other.  This 
difference  alone  would  suggest  caution  in  assimilating  too 
closely  the  two  pathological  processes. 

We  should  be  careful  not  to  limit  the  setiology  of  gout, 
much  less  its  pathology,  to  the  lithsemic  connection. 
Often  enough  the  hepatic  irregularities,  which  correspond 
in  their  clinical  manifestations  to  the  '  lithsemic  symptoms ' 


296  LITHAiMIA  AND  GOUT 

of  Murchison,  are  conspicuously  absent.  At  the  same 
time,  the  various  errors  in  diet  and  in  hygiene,  which 
sometimes  bring  about  hthsemia,  also  lead  up  to  gout ;  but 
here  again  we  perceive  alternation  rather  than  identity. 
A  patient  with  declared  gout  probably  will  not  suffer  from 
the  usual  symptoms  of  lithsemia,  and  vice  versa.  Yet  to 
become  the  subject  of  lithaemia  would  be,  for  many 
individuals,  to  invite  the  advent  of  the  gout.  The  two 
tendencies  run  on  closely  parallel  lines,  with  frequent 
junctions. 

The  most  that  can  be  said  is,  that  in  some  subjects, 
and  particularly  in  the  plethoric  and  torpid,  the  attacks 
of  the  liver  are  frequent  and  easily  provoked,  and  that  this 
is  often  evidence  of  a  progressive  goutiness. 

Looking   more   closely  into  clinical  histories,  we  may 
identify  the  tendency  as  inherent  to  certain  constitutions, 
those  naturally  or   by  habits   of  life  predisposed  to  the 
hepatic  conditions  which  determine  lithaemia.    This  brings 
us  back  to  a  consideration  without  which  neither  the  clinical 
nor  the  pathological  aspects  of  gout  can  be  thoroughly 
understood.     The  constitutions  which  become  the  bearers 
of  gout    differ  between  themselves  in  wide  degree,   and 
gouty  manifestations   are  therefore  exceedingly  various ; 
but  in  contrast  to  non-gouty  constitutions,  those  are  un- 
doubtedly more  liable  to  acquire  gout,  or  to  develop  it 
when  predisposed  by  inheritance,   into  which  enters  an 
element    of    hepatic    weakness    or    susceptibility.      The 
common  impression  that  gout  and  lithsemia  are  convertible 
terms  may,  therefore,  be  traced  to  clinical  observations  in 
themselves  correct,  though  perhaps  not  equal  to  so  large  a 
generalization  ;  and  it  may  be  held  that  a  constitutional 
peculiarity   involving   permanent    hepatic   inadequacy   or 
over-strain  would  encourage  a  liability  to  gout. 

This  is  not  all ;  the  relation  between  gout  and  the  liver 


GOUTINESS  AND  ACIDITY  297 

must  be  viewed  from  the  other  side.  Does  gout  affect  the 
Hver  in  any  way  ?  and  if  so,  is  the  influence  restricted  to 
function,  or  does  it,  as  in  the  case  of  the  kidney,  affect  also 
the  structure  ?  We  have  discussed  the  first  of  these  ques- 
tions in  the  Chnical  Section,  and  a  negative  answer  has 
been  given  to  the  second  under  the  heading  of  Patho- 
logical Anatomy. 

GOUTINESS  AND  ACIDITY. 

Excessive  acidity  is  one  of  the  most  marked  peculiarities 
of  the  gouty  state,  of  which  the  patients  themselves  are 
fully  aware.  '  An  acid  stomach  '  is  frequently  the  earliest 
foreboding  of  the  approaching  fit  of  the  gout  ;  but  undue 
acidity  is  by  no  means  limited  to  the  gastric  secretion  :  it  is 
found  in  the  urine  and  in  the  sweat.  It  also  affects  the 
blood  to  the  extent  of  diminishing  its  alkalinity ;  and  to 
this  modification  in  the  reaction  of  the  plasma  and  of  the 
juices  much  astiological  importance  is  attached  in  several 
of  the  theories  which  we  have  reviewed,  in  connection  with 
the  solubility  of  the  urates. 

Increased  local  acidity  has  been  adduced  by  Sir  W. 
Roberts,  by  Ebstein,  and  by  others,  in  explanation  of  the 
intra-articular  precipitation  of  sodium  biurate.  We  shall 
not  dwell  upon  this  more  limited  aspect  of  the  question, 
but  rather  upon  the  general  acidity  which  is  a  leading  factor 
in  the  production  of  goutiness. 

Dr.  Ralfe*  reminds  us  that  the  quantity  of  carbonic 
acid  exhaled  daily  by  a  healthy  man  amounts  to  about 
8go  grammes  (28  ounces),  and  the  quantity  of  acid  excreted 
by  the  kidney  is  equivalent  to  about  2  grammes  (31  grains) 
of  oxalic  acid,  in  addition  to  an  undetermined  amount  of 

*  '  A  Dictionary  of  Medicine,'  edited  by  Richard  Quain,  Bart.,  M.D., 
LL.D.,  F.R.S.,  1894,  vol.  i.,  p.  11. 


298  GOUTINESS  AND  ACIDITY 

volatile  fatty  acids  passing  off  with  the  sweat.  An  increase 
in  this  normal  acidity  would  result  from  an  undue  activity 
of  the  processes  which  give  rise  to  it,  or  from  some  inter- 
ference with  the  normal  process  of  excretion.  As  in  the 
case  of  uric  acid  itself,  there  may  be  (i)  an  excessive  pro- 
duction, or  (2)  a  deficient  elimination.  The  excessive  acidity 
of  goutiness  is  largely  due  to  the  latter,  and  its  source  may 
be  traced  to  an  imperfect  elaboration  of  food  and  to  an 
impaired  metabolism  of  the  tissues. 

Digestion  is  obviously  at  fault,  and  the  resulting  abnormal 
fermentation  of  the  ingesta  supplies  a  large  proportion  of 
the  acid.  Often,  however,  the  clinical  history  shows  that 
the  digestion  was  originally  sound,  and  that  the  stomach  has 
suffered  with  the  other  viscera  from  the  long  continuance 
of  conditions  affecting  the  general  nutrition.  The  diges- 
tive function  becomes  less  and  less  equal  to  the  strain 
placed  upon  it  by  an  excessive  alimentation,  and  the 
acidity  may  persist,  even  after  the  adoption  of  careful 
restrictions. 

In  other  cases  of  goutiness  the  gastric  defect  may  not 
be  prominent,  yet  acidity  will  prevail.  Faidty  metabolism, 
which  is  at  the  root  of  the  evil  in  both  groups,  comes  here 
more  largely  into  play.  According  to  Beneke,  oxidation 
within  the  tissues  is  depressed  below  the  normal  standard, 
as  part  of  a  general  slowing  of  the  chemical  processes  of 
cell-nutrition.  The  same  view  is  adopted  by  Bouchard 
and  by  Ralfe. 

Thus,  partly  owing  to  an  excess  of  nitrogenous  supplies, 
partly  owing  to  a  slowing  of  tissue  oxidation,  the  gouty 
acid  dyscrasia  goes  hand-in-hand  with  a  surplus  of  imper- 
fectly oxidized  residues,  such  as  oxalic  acid,  uric  acid,  and 
the  volatile  fatty  acids ;  and  if  the  elimination  of  the 
latter,  which  in  health  is  generally  accomplished  by  the 
skin  (formic,  valerianic,  and  butyric  acids),  by  the  intes- 


GOUT  AS  A  DISEASE  OF  FAULTY  NUTRITION     299 

tine  (cholalic  acid),  or  by  the  kidney  (uric,  hippuric, 
oxaluric  acids,  etc.),  should  suffer  a  check,  acute  gout  may 
ensue. 

GOUT  AS  A  DISEASE  OF  FAULTY  NUTRITION. 

From  the  various  aspects  under  which  we  have  con- 
sidered gout  we  derive  a  uniform  conclusion :  The  original 
gouty  defect  is  not  bound  up  with  coarse  organic  changes. 
It  is  totally  distinct  from  the  later  manifestations,  and 
especially  from  the  articular  complications.  In  contrast 
with  the  latter  it  can  hardly  be  identified  as  a  disease  ;  yet 
it  possesses  objective  reality  as  a  deviation  from  physio- 
logical function,  and  as  a  modification  of  the  normal 
metabolism  of  the  tissues.  In  a  word,  it  is  a  functional 
derangement  fraught  with  organic  consequences,  a  per- 
version of  nutrition  capable  of  producing  eventually  definite 
structural  changes. 


CHAPTER  XXXIV. 

ARGUMENTS  IN  SUPPORT  OF  THE  '  NERVOUS  ' 
THEORIES.— GOUT  AS  A  TROPHO-NEUROSIS. 

Much  has  been  made  of  an  alleged  predominance  of  a 
nervous  element  in  gout.  Cullen  regarded  the  whole 
disease  as  primarily  one  of  the  nervous  system  ;  Sir  Dyce 
Duckworth  has  advocated  the  view  of  a  presiding  neurosis ; 
Charcot,  Buzzard,  Latham,  and  others,  have  endeavoured 
to  explain  gouty  arthritis  in  connection  with  some  affection 
of  an  assumed  joint-centre,  either  medullary  or  spinal. 
All  three  views,  with  varying  definiteness,  claim  for  the 
nervous  system  control  over  organic  processes  of  life. 
Does  this  power  exist  ? 

ON  NERVE  ENERGY  AND  ITS  MISDIRECTIONS. 

Of  the  nature  of  nerve  energy,  and  of  its  mode  of  dis- 
tribution, we  know  little,  except,  perhaps,  that  we  possess 
some  power  of  converging  or  concentrating  it.  We  can 
at  times  definitely  trace  the  influence  of  thought  on 
function. 

The  oft-quoted  case  of  Colonel  Townshend,  who  willed 
himself  to  die,  and  died,  is  a  popular  illustration  of  the 
influence  in  question.  Again,  the  power  of  the  mesmerizer 
and  the  catalepsy  of  the  mesmerized  are  familiar  wonders ; 
and  pathology  also  supplies  us  with  instances  in  point. 


ON  NERVE  ENERGY  AND  ITS  MISDIRECTIONS     301 

whilst  the  cases  of  anorexia  nervosa  exempHfy  the  degree  to 
which  nutrition  may  suffer  under  unhealthy  innervation. 
But  the  greatest  wonder  of  all  is  that  generally  referred  to 
under  the  name  of  '  maternal  impressions.'  These  extra- 
ordinary instances  of  a  misdirection  of  energy  help  us  to 
recognise  the  possibility  of  disturbances  less  extreme. 
Derangements,  functional  at  first,  and  ultimately  struc- 
tural, perhaps  arise  from  an  imperfectly-balanced  distribu- 
tion of  nerve  force. 

Our  present  civilization  '  on  wheels  and  on  wires  '  tends 
to  upset  the  balance  in  favour  of  nerve  stimulation. 
Whilst  saving  muscular  work,  it  draws  perhaps  too  heavily 
upon  our  reserve  of  nerve  energy. 

The  Morbid  Predominance  of  the  Nervous  System. — In  all 
processes  affecting  the  economy  as  a  whole,  the  lion's  share 
belongs  to  the  nervous  system ;  and  it  is  remarkable  that, 
with  increasing  malnutrition,  the  steps  in  the  hierarchy 
of  the  tissues  deepen,  the  nervous  system  remaining  further 
and  further  above  all  others.  In  actual  starvation  the 
nervous  tissues  hardly  lose  weight  before  the  others  have 
wasted. 

As  in  starvation,  or  as  in  general  malnutrition,  each 
tissue  would  suffer  in  its  own  degree  and  in  its  own  way, 
the  joints  in  the  direction  of  arthritis,  the  nervous  system 
in  the  way  of  irritability. 

The  excessive  nervous  irritability  which  arises  from  general 
weakness  is  strikingly  illustrated  in  the  nervous  manifesta- 
tions, often  mistermed  hysterical,  to  which  the  more 
emotional  sex  is  liable  under  temporary  exhaustion.  The 
case  of  the  gouty  is  distinctly  analogous.  Heredity,  or 
the  long  preponderance  of  nerve  function,  has  brought  into 
prominence  the  nervous  bias,  and  the  nervous  system  is 
ready  for  a  special  and  excessive  response  to  the  operation 
of  any  general  cause,  such  as  gout. 


302    NERVE  INFLUENCE  IN  CONSTITUTIONAL  GOUT 

A  controlling  capacity  of  the  nervous  system  for  the 
processes  of  nutrition  might  thus  be  admitted — at  least, 
for  the  sake  of  argument.  Let  us  now  examine  in  which 
ways  it  might  operate  in  gout. 


THE  NERVOUS  INFLUENCE   IN   THE   PRODUCTION   OF 
CONSTITUTIONAL  GOUT  OR  GOUTINESS. 

It  is  difficult  to  define  the  alleged  influence  on  the 
general  metabolism.  The  use  of  the  word  '  neurosis ' 
helps  thought  by  the  analogy  it  suggests  with  familiar  and 
tangible  clinical  results.  If  gout  were  a  neurosis,  much 
evidence  would  point  to  its  being  a  neurosis  of  the  trophic 
mechanisms.     Unhappily,  neurosis  itself  is  a  mystery. 

A  misdirected  nerve  energy  might,  it  is  alleged,  set  up  a 
functional  disorder  leading  up  to  structural  changes.  In 
favour  of  this  view  there  is  the  anatomical  fact  that  the 
visceral  and  the  cerebral  spinal  nervous  systems  are  in 
continuity,  the  physiological  fact  that  these  two  nervous 
departments  co-operate  and  mutually  react  upon  each 
other,  as  shown  experimentally  by  the  atrophy,  lower 
temperature,  etc.,  of  parts  experimentally  deprived  of 
innervation,  and,  lastly,  the  clinical  facts  within  every 
physician's  knowledge.  It  is  a  matter  of  daily  observation 
that  the  abrupt  cessation  of  habitual  muscular  activity, 
by  disturbing  the  balance  of  nerve  force,  will  deter- 
mine an  attack  of  gout,  whilst  excessive  muscular  fatigue 
may  have  a  like  result.  Again,  extensive  expenditure 
of  nerve  force  from  over-study,  over-anxiety,  grief,  mental 
shock,  depressing  circumstances  or  illnesses,  insomnia, 
sexual  excesses,  or  even  peripheral  lesions,  is  a  fertile 
source  of  gouty  excitations.  Neither  should  we  overlook 
the  significant  frequency  of  an  association  of  diabetes 
with  gout. 


NERVE  INFLUENCE  IN  CONSTITUTIONAL  GOUT    303 

On  these  grounds  it  would  be  hard  to  deny  to  the 
nervous  system  a  leading  share  in  the  evolution  of  the 
gouty  phenomena ;  and  possibly  it  may  play  a  directive 
part  by  influencing  metabolism,  or  even  the  growth  or 
destiny  of  cells,  whether  fixed  or  migratory.  Beyond  this 
we  hesitate  to  proceed.  The  attempt  to  localize  the 
primary  defect  in  any  one  part  of  the  nervous  system 
is  scarcely  justified  by  facts.  At  most  an  argument  might 
be  derived  from  the  facts  of  experimental  diabetes  and  of 
diabetes  insipidus,  of  phosphaturia,  of  Addison's  disease, 
and  similar  neuro-trophic  disorders ;  but  analogy  is  not 
safe  ground  to  build  upon. 

Contenting  ourselves,  then,  with  a  broad  and  vague 
statement,  we  might  regard  gout  as  possibly  connected 
with  a  misdirection  of  constructive  energy  under  the 
administration  of  the  nervous  system.  Abrupt  deviations 
might  be  set  up  by  accidental  and  temporary  causes.  Of 
this  kind  would  be  the  phenomena  of  acute  and  isolated 
gouty  attacks.  Chronic  deviations  would  result  from  the 
continued  stress  of  more  prolonged  influences  ultimately 
leading  to  general  structural  changes,  in  the  course  of 
which,  again,  the  more  temporary  excitations  would  bring 
about  the  various  local  or  visceral  manifestations. 

According  to  this  interpretation  of  the  facts,  the  advent 
both  of  acute  and  of  chronic  gout  might  be  in  part  deter- 
mined by  nervous  mechanisms.  Meanwhile,  the  essential 
morbid  process,  which  is  to  be  identified  by  its  two  great 
features  or  results — undue  presence  of  uric  acid  and  in- 
creasing delicacy  or  vulnerability  of  structures — must  be 
regarded  as  a  general  affection  of  nutrition  involving  all 
tissues ;  the  nervous  system,  as  in  starvation  and  as  in  old 
age,  being  the  last  to  degenerate,  although  its  conscious  or 
declared  sufferings  may  be,  as  belongs  to  the  most  re- 
active of  tissues,  absolutely  the  earhest  in  the  record. 


304        NERVE  INFLUENCE  IN  GOUTY  ARTHRITIS 

It  is  just  possible  to  think  of  the  acute  attack,  per  se,  as 
some  sudden  and  stormy  disorder  of  the  nervous  system 
upsetting  the  balance  of  metabolism  or  of  nutrition.  It 
is  also  possible  to  think  of  the  excess  of  uric  acid  as  one 
of  the  results  of  a  disturbance  of  the  metabolism  of  the 
body,  induced  under  the  influence  of  the  nervous  system. 
But  all  this  is  mere  speculation. 

The  transmission  of  goutiness  v^^ould,  according  to  this 
view,  be  determined  by  nervous  agency  in  a  manner  some- 
what analogous  to  the  production  of  irregularities  in  fcetal 
development  from  mental  impressions  in  the  mother. 


THE  NERVOUS  INFLUENCE  IN  THE  PRODUCTION  OF 
GOUTY  ARTHRITIS. 

The  Alleged  Joint-centre. — A  considerable  step  is  taken 
in  pure  theory  when,  instead  of  a  supposed  influence  on 
the  general  metabolism  of  the  body,  we  are  told  that  the 
liability  of  the  joints  to  gouty  inflammation,  is  directly 
determined  through  a  nerve  centre.  This  development 
of  the  theory  which  attributes  to  the  nervous  system 
a  controlling  power  over  tissues,  needs  proof  in  propor- 
tion to  the  definiteness  of  the  alleged  localization  ;  and 
this  proof  is  still  wanting. 

We  have  referred  in  another  section  to  the  arguments 
used  by  the  chief  supporters  of  a  joint-centre.  Rendu 
likewise  draws  attention  to  the  determining  agency  of 
affections  of  the  cerebro-spinal  system,  and  to  the 
frequency,  in  acute  and  chronic  diseases  of  the  spinal 
cord,  of  arthropathies  simulating  rheumatism,  a  connec- 
tion which  might  explain  the  Protean  forms  of  rheumatism 
as  well  as  those  of  gout. 


THEORIES  OF  GOUTY  ARTHRITIS  305 


THE   TOXIC,    MECHANICAL,   NERVOUS,  AND   NEURITIC 
THEORIES  OF  GOUTY  ARTHRITIS. 

The  remaining  varieties  of  the  nervous  theory  differ 
much  in  their  explanations  of  the  mechanism  of  gouty 
arthritis. 

The  Toxic  Theory  affords  httle  scope  for  the  local  opera- 
tion of  the  nervous  system  as  a  direct  cause.  The  local 
acidity  of  the  joints  themselves,  which  has  been  insisted 
on  by  some  authors,  would  be  difficult  to  explain  through 
a  local  nervous  influence.  On  the  other  hand,  general 
acidity  might  be  satisfactorily  accounted  for  through  dis- 
turbed innervation  of  the  metabolic  glands. 

It  is  quite  conceivable  that  the  inflammation  may  be 
due  to  toxic  rather  than  to  mechanical  irritation.  We 
should  bear  in  mind  that,  besides  uric  acid,  which  appeals 
to  the  eye,  there  are  all  the  invisible  products  of  metabolism 
to  be  reckoned  with,  and  above  all,  those  acid  products 
which  seem  capable,  as  in  gouty  or  in  simple  urticaria,  of 
determining  cutaneous  oedema,  or,  as  in  rheumatic 
arthritis,  of  bringing  about  severe  and  painful  inflam- 
mation. The  gouty  acidity  of  the  joints  is  sometimes 
adduced  as  an  explanation  for  the  precipitation  of  the 
crystals  ;  might  it  not  be  the  cause  of  the  irritation  and 
inflammation  itself,  as  we  find  this  to  be  the  case  in 
rheumatism  where  no  solid  irritant  is  present  ? 

This  view  of  gouty  arthritis  would  not  exclude  uric  acid 
deposition  as  an  invariable  concomitant.  Although 
Rendu*  adduces  Potain's  observations,  to  the  effect  that  a 
gouty  person  may  present  no  appreciable  trace  of  uric  acid 
in  the  blood  (whilst  uricacidaemia  is  frequently  found  in 
conditions  totally  distinct  from  gout),  we  must  adhere  to 

*  Loc.  cit.,  pp.  200,  206. 

20 


3o6  THEORIES  OF  GOUTY  ARTHRITIS 

the  view,  so  largely  supported  by  evidence,  that  uric- 
acidsemia  is  an  essential  part  of  declared  gout. 

The  Mechanical  Irritation  Theory. — Here,  again,  we  fail  to 
see  how  the  nervous  system  could  prove  a  determining 
agent.  Precipitation  of  uric  acid  must,  as  pointed  out  by 
Sir  W.  Roberts,  be  essentially  a  chemical  process,  imme- 
diately influenced  by  the  state  of  the  juices  rather  than 
of  the  tissues.  On  the  other  hand,  nerve  irritation  may 
arise  from  the  deposition ;  this  is  an  inference  admitted 
by  all. 

In  connection  with  the  alleged  mechanical  irritation  by 
the  pointed  crystals,  which,  after  all,  are  safely  embedded 
in  the  indifferent  and  relatively  insensitive  nerveless  tissues 
of  cartilage,  we  are  reminded  of  the  behaviour  of  a  variety 
of  most  sensitive  tissues  in  which  sewing  needles  may 
travel  without  occasioning  pain  or  consciousness  of  their 
presence. 

It  has  been  admitted  by  authorities  that  acute  arthritis 
has  sometimes  after  an  interval  left  no  trace  of  uratic 
deposit  in  the  joint  affected.  We  should  like  to  be  assured 
on  this  point  by  further  observations.  If  this  were  true, 
the  view  that  the  inflammation  was  necessarily  due  to  the 
irritation  of  cartilage  or  fibrous  tissue  by  sharp  crystals 
would  fall  to  the  ground.  Irrespective  of  any  such 
evidence,  this  coarse  mechanical  explanation  seems  to  be 
open  to  much  doubt.  Less  improbable  would  be  a 
mechanical  irritation  of  nerves  ;  but  we  have  not  hitherto 
recognised  any  crystals  in  the  nerve  substance,  although 
the  oedema  and  congestion  are  such  as  might  result  from 
nerve  irritation. 

The  remaining  theories  appeal  directly  to  a  nervous 
factor. 

The  Nervous  Theory  regards  the  acute  inflammation  as 
determined  by  some  nerve  influence  acting  directly  or  in- 


THEORIES  OF  GOUTY  ARTHRITIS  307 

directly  upon  the  joint.  The  direct  form  would  be  that 
suggested  by  the  advocates  of  a  joint  centre  ;  the  indirect 
form  is  practically  an  instance  of  vaso-motor  influence. 
Thus,  Rendu  regards  '  articular  congestion  '  under  nerve 
influence  as  the  dominant  feature  of  the  attack.  He  does 
not  explain  the  mode  of  irritation,  nor  does  he  state  the 
nature  of  the  irritant.  He  reminds  us  that  acute  gout 
in  the  joints  is,  like  acute  rheumatic  arthritis,  often  trace- 
able to  an  impression  of  cold,  and  that  this  must  operate 
through  some  nervous  agency.  There  is,  at  any  rate, 
nothing  irrational  in  the  view  that  the  congestion  and  the 
oedema  may  be  partly  due  to  nerve  irritation  leading 
reflexly  to  local  vaso-dilatation. 

Sir  W.  Wade's  Neural  Theory*  seeks  to  explain  the  local 
gouty  attack  as  a  local  neuritis.  He  also  traces  the 
visceral  manifestations  to  the  influence  of  the  dyscrasia 
on  the  nervous  centres.  This  is  distinctly  a  neuro-humoral 
theory,  but  one  allotting  to  uric  acid  a  less  direct  share 
than  others.  The  uric  acid  would  act  on  the  nerves  first, 
and  through  their  agency  would  influence  the  joints  or  the 
tissues. 

As  stated  by  Sir  W.  Wade,  '  There  is  not  much  analogy 
between  the  special  tissues  of  a  joint  and  those  of  a 
mucous  membrane ;  and  into  a  mind  dominated  by  the 
idea  that,  without  a  joint,  localized  gout  is  not  possible, 
it  is  easy  to  see  that  the  idea  of  gout  in  the  mucous 
membrane  will  enter  with  difficulty.' 

We  will  not  attempt  to  discuss  this  view  of  the 
mechanism  of  visceral  gout.  In  connection  with  gouty 
arthritis  the  neural  theory  has  great  interest.  Sir  W. 
Wade  has  applied  to  the  explanation  of  the  phenomena 
the  latest  of  our  discoveries  in  nervine  pathology,  that  of 
peripheral  neuritis.     Instead  of  placing  the  lesion  in  the 

*  C/.  p.  254  e^  seq. 


3o8  GOUT  AS  A  TROPHO-NEUROSIS 

central  nervous  system,  he  localizes  it  in  the  nerves  of  the 
inflamed  limb. 

It  would  be  premature,  before  the  clinical  facts  have 
been  more  fully  tested,  to  reject  the  explanation  which 
Sir  W.  Wade  has  put  upon  them.  An  obvious  difficulty 
in  accepting  it  has  already  been  mentioned.*  It  may  be 
questioned  whether  the  changes  special  to  neuritis  would 
have  time  to  evolve  and  to  disappear  within  the  brief 
duration  of  some  of  the  attacks.  An  acute  inflammation 
of  the  lymphatics  of  the  nerve-sheath,  or  an  acute  con- 
gestion of  the  vasa  nervorum,  would  be,  in  this  respect, 
more  consistent  with  the  possibilities  of  the  case. 

GOUT  AS  A  TROPHO-NEUROSIS. 

We  may  assume,  with  Rendu,  that,  while  the  original 
fault  lies  with  nutrition  and  with  digestion,  the  nervous 
system  has  an  undoubted  influence  on  the  metabolic 
exchanges  and  on  assimilation,  and  that  it  also  exercises 
a  determining  influence  upon  some  of  the  acute  pheno- 
mena of  gout.  We  must  own,  however,  that  the  subtle 
mechanism  of  these  influences  is  still  unexplained.  It  is 
no  less  mysterious  than  the  mechanism  by  which  the 
occurrence  of  a  severe  articular  attack  often  frees  the 
patient  from  his  previous  ill-health.-f- 

*  Cf.  p.  258. 

f  Garrod  explains  the  gouty  trouble  as  due  to  an  excess  of  uric 
acid,  which  is  removed  from  the  circulation  by  precipitation  into  the 
joints,  and  he  supposes  that  the  uric  acid  itself  is  destroyed  by  the 
agency  of  inflammation  ;  but  Rendu  points  out  that,  whilst  it  is  argued 
that  the  deposit  of  urate  sets  up  arthritis,  and  the  arthritis  destroys 
the  uric  acid,  in  tophaceous  gout  there  is  neither  much  inflammation, 
on  the  one  hand,  nor  at  first  any  destruction,  but  a  growing  accumula- 
tion of  the  deposit.  Moreover,  he  points  out  that  Garrod  {c/.  loc.  at., 
p.  386)  has  observed  deposits  in  the  joints  of  patients  who  had  never 
complained  of  gouty  symptoms. 


GOUT  AS  A  TROPHO-NEUROSIS  309 

'  Neurosis  '  or  '  tropho-neurosis  '  may  be  used  as  a 
name  for  this  ill-defined  agency,  but  there  is  no  adequate 
proof  that  the  nervous  system  is  independently  and 
primarily  responsible  for  the  production  of  gout.  On  the 
contrary,  we  hold  that,  in  common  with  the  mucous  and 
cutaneous  surfaces,  and  with  the  internal  structures,  it 
bears  its  share  of  the  original  alterations  in  the  nutritive 
process.  Its  morbid  excitability  may  intensify  the  changes 
progressing  in  other  tissues,  but  in  this  there  is  nothing 
for  which  a  parallel  might  not  be  found  in  other  diseases 
not  reckoned  as  primarily  nervous. 


CHAPTER  XXXV. 

CONCLUDING  PROPOSITIONS. 

Aret^us  of  Cappadocia  has  told  us  that  '  of  the  nature 
of  gout  none  but  the  gods  have  a  true  understanding.' 
This  thought  may  allay  some  of  the  disappointment  to 
which  our  present  labours  are  doomed.  We  have  not 
strictly  defined  gout.  Nevertheless,  important  approaches 
will  have  been  secured  if  the  foregoing  analysis  of  the 
subject  should  have  succeeded  in  establishing  the  following 
points. 

1.  The  assumption  of  the  unknown  factor  '  diathesis  '  is 
unnecessary  ;  and  we  regard  the  word  as  also  superfluous. 

2.  Objectively,  we  deal  with  two  states — gout  and  gouti- 
ness ;  and  these  names  fairly  express  the  relations  and  the 
differences  existing  between  them.  One  state  maj^  never 
pass  into  the  other.  More  commonly  goutiness  inclines 
almost  fatally  towards  declared  gout ;  and,  with  few  ex- 
ceptions, those  once  attacked  with  declared  gout  lapse, 
sooner  or  later,  into  goutiness. 

3.  '  Articular  or  Declared  Gout '  is  the  tangible  result 
of  a  constitutional  change,  which,  in  the  acquired  form,  is 
not  at  first  obvious. 

4.  '  Goutiness '  is  applicable  to  all  the  conditions  in 
which  the  constitutional  change  is  manifest,  though  declared 
gout  may  be  altogether  absent,  or  present  only  at  long 
intervals. 


CONCLUDING  PROPOSITIONS  311 

The  evidence  of  goutiness  may  be  partly  structural,  as  in 
the  delicacy  of  the  tissues  of  those  who  inherit  the  affec- 
tion ;  but  in  all  cases  it  is  also  functional,  and  is  made  up 
of  the  gouty  visceral  manifestations. 

5.  Gout  and  goutiness,  which  diverge  in  their  symptoms, 
are  merged  into  one  at  their  origin.  Their  aetiology  is 
identical,  and  their  treatment,  so  far  as  it  is  based  upon 
their  aetiology,  is  the  same.  We  have  no  choice  but  to 
regard  that  which  they  possess  in  common  as  the  essential 
part  in  them,  and  that  which  they  separately  exhibit  as  the 
less  essential  and  secondary  part. 

6.  Marked  uricacidcemia  and  demonstrable  deposits  of 
biurates  are  the  features  of  declared  gout.  They  are  not 
prominent  features,  and  may  be  even  sometimes  absent 
in  goutiness. 

7.  Conversely,  the  train  of  visceral  irregularities  and 
disorders  characteristic  of  goutiness  form  no  integral  part 
of  declared  gout.  On  the  contrary,  their  appearance  is 
almost  evidence  that  arthritic  gout  is  in  abeyance ;  and  an 
occasional  conjunction  of  the  two  sets  of  symptoms  is  an 
exception  which  confirms  the  rule. 

8.  Our  inability  to  dissever  the,  practically  speaking, 
identical  constitutional  conditions  of  goutiness  and  of  gout 
carries  with  it  the  conclusion  that  their  diverging  manifes- 
tations cannot  be  regarded  as  synonymous  with  the 
essence  of  the  affection.  They  are  merely  results  derived 
from  the  latter.  This  conclusion  would  dispose  of  the 
view  that  gout  (in  the  more  comprehensive  acceptation  of 
the  term)  is  nothing  more  than  a  uric  acid  dyscrasia*     It 

*  Were  excess  of  uric  acid,  whether  due  or  not  to  leucocytosis,  alone 
responsible,  gout  would  be  one  of  the  characteristics  of  leucocythaemia  ; 
we  should  find  it  very  frequently  among  children,  whose  uric  acid  pro- 
duction is  great  ;  it  should  be  a  never-failing  result  of  certain  habits 
of  life  and  diet  leading  to  daily  and  excessive  poliferation  of  leucocytes* 


312  CONCLUDING  PROPOSITIONS 

further  implies  the  necessity  of  dissociating  the  considera- 
tion of  the  phenomena  of  goutiness  from  that  of  the 
phenomena  of  arthritic  gout,  which  are  closely  connected 
with  an  excess  and  a  faulty  disposal  of  uric  acid. 

g.  Turning  first  to  declared  articular  gout,  we  do  not  find 
absolute  evidence  as  to  the  nature  of  its  connection,  un- 
deniably a  close  one,  with  the  deposition  of  biurates. 
Different  opinions  are  still  entertained  as  to  whether  the 
original  deposition  is  the  cause,  the  accompaniment,  or  the 
result,  of  the  local  affection ;  and  between  them  we  have 
no  means  of  deciding. 

10.  There  is  no  doubt  whatever  that  the  late  articular 
changes  are  the  direct  result  of  the  local  accumulation  of 
sodium  biurate.  Our  knowledge  of  the  mechanism  of 
these  changes  is  the  most  advanced  department  in  the 
pathology  of  gout,  and  its  early  elucidation  has  largely 
contributed  to  a  perhaps  premature  acceptance  of  the 
uric  acid  theory  of  gout. 

11.  Goutiness  presents  us  with  a  widely  different  picture, 
the  main  feature  of  which  is  a  general  change  both  functional 
and  structural,  the  localizations  of  which  are  accidentally 
determined  by  individual  peculiarities  of  the  subject,  and 
the  circumstances  of  his  environment. 

12.  The  functional  change,  as  it  affects  the  juices,  is 
abnormal  acidity ;  as  it  affects  the  tissues,  increased  irrita- 
bility and  lowered  resistance. 

13.  The  structural  change  is  minute  in  proportion  to  its 
wide  extent,  and  it  probably  could  not  be  detected  by  the 
microscope  in  individual  cells.  It  is  nevertheless  obvious  ; 
most  marked  is  the  modification  of  the  external  epithelium, 
and  particularly  that  of  the  nails,  which  show  decided 

None  of  these  results  are  invariably  observed.  It  would  be,  therefore, 
idle  to  lay  exclusive  stress  upon  excess  of  uric  acid  or  the  agency  of 
leucocytosis  in  the  production  of  gout. 


CONCLUDING  PROPOSITIONS  313 

thinning.  The  same  structural  dehcacy  may  be  inferred 
to  exist  in  the  nervous  system  from  a  consideration  of 
its  functional  relations  to  the  skin,  and  of  the  marked 
increase  in  its  excitability,  and  in  all  the  tissues  on 
the  grounds  of  their  increased  vulnerability. 

14.  The  question  arises  whether  this  degeneracy  is 
merely  the  work  of  a  long  continuance  of  the  acid 
dyscrasia,  or  whether  it  is  connected  with  some  deeper- 
seated  cause  residing  in  the  cells  themselves.  The  former 
supposition  is  discouraged  by  the  remarkable  circumstance 
that  the  structural  delicacy  is  transmitted  to  the  offspring, 
and,  indeed,  is  commonly  noticed  in  the  offspring  of  those 
who  have  acquired  gout,  although  it  may  not  have  been 
perceptible  in  the  parent. 

15.  Looking  back  into  the  chnical  history  of  the 
subjects  who  acquire  gout  through  high  living,  we  often 
fail  to  trace  any  previous  tendency  to  acidity.  They  are 
usually  endowed  with  an  originally  strong  digestion,  which 
only  gives  way  at  the  approach  of  the  gouty  stage. 
Moreover,  extreme  acidity  is  presented  by  many  subjects 
who  do  not  develop  the  slightest  tendency  to  gout.  The 
mode  of  origin  of  acquired  gout  in  itself  suggests  the 
operation  of  some  nutritional  disorder,  whilst  the  result 
of  this  nutritional  defect  is  obvious  in  the  eventual  relative 
atrophy  of  the  tissue  elements. 

16.  It  is  conceivable  that,  as  suggested  by  Beneke,  the 
undue  acidity  may  be  itself  the  by-product  of  the  faulty 
metamorphosis  of  cells.  This  would  explain  its  persistence 
in  inherited  goutiness,  even  when  metabolism  is  no 
longer  oppressed  and  depressed  by  a  reckless  excess  of 
ingesta.  According  to  this  view,  a  depressed  and  faulty 
metaboHsm  would  be  the  first  departure,  and  abnormal 
secretion  would  be  its  outcome. 

17.  Assuming  the  correctness  of  Beneke's  view,  we  find 


314  CONCLUDING  PROPOSITIONS 

in  the  phenomena  of  goutiness  a  much  nearer  approach 
to  some  primary  or  essential  factor  than  in  articular  gout. 
In  the  functional  disturbances  of  the  various  organs  we 
are  brought  distinctly  nearer  those  intimate  changes  in 
nutrition  whereby  the  power  of  resistance  of  tissues  is 
lowered. 

Indeed,  goutiness  is  in  varying  degrees  the  basis  of  all 
articular  gout,  but  most  manifestly  of  that  which  is 
inherited. 

i8.  The  derivation  of  an  excess  of  uric  acid  from  the 
tissues,  as  suggested  by  Horbaczewski's  researches,  is 
consonant  with  the  view  that  gout  is  essentially  a  condi- 
tion of  perverted  nutrition.  At  any  rate,  it  is  highly 
probable  that  the  increased  uric  acid  production,  which 
is  undoubtedly  caused  by  an  excessive  nitrogenous  diet,  is 
not  largely  derived  from  the  nitrogenous  foods  in  transitu, 
but  is  the  result  of  an  altered  catabolism  of  the  cell- 
substance,  which  is  imperfectly  carried  out  by  reason 
of  the  paralyzing,  and  in  that  sense  toxic,  effect  of  the 
nitrogenous  excess. 

ig.  The  persistence  of  the  faulty  metabolism  when  the 
original  cause  is  no  longer  at  work  is  difficult  to  explain. 
The  difficulty  has  given  rise  to  the  notion  of  a  '  gouty 
diathesis.'  We  prefer  to  deal  with  more  tangible  explana- 
tions, whilst  allowing  a  large  margin  for  the  operation 
of  individual  peculiarity  which  leads  in  so  many  diseases, 
as  well  as  in  gout,  to  the  immunity  of  some  and  to  the 
liability  of  others  when  placed  under  apparently  identical 
conditions.  The  force  of  habit  is  traceable  in  cellular 
activities,  as  well  as  in  the  higher  mechanisms  of  action  ; 
it  has  been  used  as  the  mainspring  of  the  theory  of  evolu- 
tion, and  may  with  equal  probability  be  applied  to  the 
problem  of  the  inheritance  of  gout.  To  say  that  the 
'  gouty  diathesis  '  resides  in  the  nervous  system  '  because 


CONCLUDING  PROPOSITIONS  315 

the  latter  governs  all  other  tissues  '  is  merely  to  shift  the 
chief  operation  of  this  force  of  habit  from  the  rank  and 
file  to  the  headquarters  of  the  organism.  There  is  much 
in  favour  of  the  view  that  the  habit  of  faulty  cellular 
metabolism  is  largely  kept  up  by  the  habit  of  faulty 
innervation ;  but  this  in  noways  affects  the  proposition 
that  all  cells,  including  the  nerve-cells,  are  in  their  various 
capabilities  under  the  lasting  influence  of  the  original 
deviation  from  healthy  metabolism  induced  by  a  prolonged 
course  of  toxic  alimentation. 

20.  The  explanation  suggested  has  its  practical  bearing. 
Instead  of  a  diathesis  which  needs  '  eradicating,'  we 
conceive  of  a  faulty  habit  slowly  acquired  which  needs 
replacing  by  a  healthy  habit,  the  growth  of  which  must 
also  be  slow.  This  consideration  must  guide  our  treat- 
ment ;  it  also  encourages  a  belief  in  the  curability  of 
goutiness,  though  not  of  the  late  results  of  articular  gout. 

21.  A  general  change,  such  as  hinted  at,  must  affect 
each  element  in  the  line  of  its  special  activity.  Among 
organs  there  are  those  whose  fimction  is  metabolism.  That 
their  deviation  from  healthy  function  should  take  effect 
out  of  comparison  with  that  taken  by  other  organs  is 
self-evident.  To  this  group  belong  the  stomach,  small 
intestine  and  lacteals,  the  pancreas  and  spleen,  and,  above 
all,  the  liver.  Without  attributing,  with  Murchison,  the 
whole  blame  to  the  liver,  we  attach  to  its  shortcomings 
a  considerable  share  of  responsibility ;  and  in  this  we 
rely  less  on  experimental  evidence,  for  it  does  not  furnish 
us  with  any  conclusions,  than  on  clinical  observation  of 
the  events,  and  of  the  action  of  remedies. 

22.  Plethora  has  long  been  recognised  as  favouring  the 
development  of  gout.  Scudamore  and  Gairdner  have, 
indeed,  regarded  blood  -  plethora  as  its  primary  agent. 
Undue    vascular    fulness,    but    particularly   that    of   the 


3i6  CONCLUDING  PROPOSITIONS 

portal  system,  may,  as  alleged,  have  a  retarding  influence 
on  metabolism ;  but  it  might  also  be  suggested  that  the 
normal  organic  activities  should  be  sufficient  to  clear 
away  the  superfluous  fluid.  Indeed,  on  this  point,  the 
success  of  a  corrective  treatment  leaves  us  in  little 
doubt. 

23.  Gout  is  largely  a  renal  question.  The  compensating 
relation  so  clearly  shown  during  the  attack  between  the 
joints  and  the  kidney  in  connection  with  the  disposal 
of  uric  acid  is  significant.  Whilst  the  kidney  refuses 
passage  to  it,  the  joints  receive  it ;  but  this  relation  is 
quickly  reversed,  the  renal  function  of  the  latter  being 
restored,  so  far  as  we  can  judge,  completely,  even  within 
the  duration  of  a  paroxysm.  The  subject  of  renal  im- 
permeability has  been  sufficiently  discussed. 

24.  Again,  much  of  the  prognosis  of  gout  gravitates 
round  the  state  of  the  kidney.  Its  modern  pathology 
might  be  compared  to  a  vicious  circle,  of  which  the 
kidney  is  the  centre.  '  Renal  defect  originates  the  uric 
acid  trouble,  which,  once  started,  may  end  in  destroying 
the  kidney.' 

25.  We  are  not  warranted  in  regarding  the  kidney  as 
the  organ  originally  affected,  since  in  some  of  the  most 
stormy  gouty  attacks  minimal  changes  only  exist  in  the 
kidney,  often  so  slight  as  not  to  produce  albuminuria. 

A  strong  reason  for  regarding  the  gouty  trouble  as  one 
sui  generis  is  that  severe  disease  of  the  kidney  need  not 
per  se  lock  in  the  uric  acid  or  produce  gout. 

Were  renal  disease  in  itself  capable  of  bringing  about 
the  uric  acid  disturbance  and  gout,  all  cases  of  lead 
intoxication  should  develop  gout  sooner  or  later ;  this  is 
far  from  being  the  case.  Again,  all  sufferers  from  granular 
kidney  ought  to  present  evidence  of  accumulation  of  uric 
acid,  and  in  other  forms  of  chronic  nephritis  there  ought 


CONCLUDING  PROPOSITIONS  317 

to  be  at  least  some  indication  of  the  uric  acid  excretion 
being  interfered  with.  From  the  relatively  small  propor- 
tion of  cases  of  gout  occurring  among  these  various  groups, 
we  conclude  that  some  other  factor  besides  renal  in- 
adequacy is  necessary  to  determine  the  result. 

26.  Modern  research  indicates  that,  as  suggested  by 
Parkes  and  others,  there  are  two  main  aspects  to  gout— 
the  degenerative  changes  in  the  tissues,  and  the  uric  acid 
trouble — and  that  these  may  be  simply  the  two  phases 
of  a  single  process  connected  with  cell  malnutrition. 

27.  In  advanced  gouty  cachexia  the  co-existence  of  a 
prevailing  systemic  change  by  the  side  of  the  local 
affection  is  obvious.  We  have  strong  reason  to  believe 
that  at  earlier  stages  also  the  entire  man  is  gouty,  not 
the  suffering  joint  only.  In  inherited  goutiness  structural 
change  is  likewise  often  manifest  prior  to  any  articular 
attacks.  In  acquired  gout  the  constitutional  change  some- 
times precedes  the  stage  of  acute  articular  attacks  ;  it 
usually  becomes  established  only  after  their  frequent 
repetition. 

28.  The  frequent  absence  of  a  well-marked  pre-arthritic 
stage  of  goutiness  in  first  acute  attacks  is  partly  explained 
in  connection  with  the  fine  balance  preserved  by  an  essen- 
tially precarious  health  in  all  gouty  states.  The  facility 
with  which  the  balance  is  overthrown  suggests  that  latent 
changes  may  have  taken  place  unsuspected. 

29.  This  characteristic  instability,  due  to  increased 
irritability  and  diminished  resistance  in  the  tissues,  may 
explain  the  recurrences  witnessed  under  subtle  influences, 
such  as  changes  of  season,  etc. 

30.  Gout  would  seem  to  be  a  typical  instance  of  the 
ultimate  evolution  of  structural  changes  from  an  affection 
at  first  almost  entirely  functional,  and  therefore  capable 
of  being;  controlled. 


3i8  CONCLUDING  PROPOSITIONS 

Coarse  structural  changes  are  connected  with  the  faulty 
disposal  of  the  uric  acid.  They  constitute  a  totally 
distinct  and  secondary  process,  which  should  be  separately 
considered. 

Structural  changes  of  a  much  finer  kind,  affecting  the 
entire  organism,  are  those  resulting  from  a  faulty  meta- 
bolism. Only  after  a  long-continued  operation  of  their 
causes  do  they  become  manifest.  Their  full  development 
is  witnessed  in  the  gouty  cachexia  of  the  late  stages.* 

We  thus  distinguish,  by  the  side  of  that  deep-seated 
functional  defect  or  error  which  determines  gout,  two 
progressive  structural  changes — the  one  directly  affecting 
cell-growth  in  general ;  the  other  secondary,  and  limited  to 
those  tissues  and  organs  in  which  the  biurate  is  deposited. 

31.  The  fact  that  gout  may  be  acquired  (all  gout  traced 
sufficiently  far  back  must  have  been  acquired  gout)  points 
to  its  functional  derivation.  The  fact  that  it  may,  together 
with  certain  visible  peculiarities  recognised  as  gouty,  be 
inherited,  shows  that  its  later  development  involves  struc- 
tural changes  in  the  subject  who  has  acquired  it.  These 
are  the  characteristics  of  a  disease  of  faulty  nutrition. 
The  history  of  acquired  gout  is  one  of  functional  disorder 
leading  up  to  organic  lesions,  whilst  the  history  of  in- 
herited gout  is  often  that  of  textural  delicacy,  leading  to 
functional  disorders. 

32.  The  joints  are  delicate  reagents  for  certain  toxic  sub- 
stances, less,  perhaps,  owing  to  any  high  degree  of  sensi- 
tiveness, than  owing  to  the  slowness  of  the  circulation  of 
fluids  through  their  substance,  and  to  the  peculiarity  of 

*  In  inherited goict  some  part,  at  least,  of  the  fine  structural  changes 
is  handed  down,  and  the  uric  acid  troubles  are  called  forth  on  com- 
paratively trifling  provocation.  But  since  some  structural  gouty  pecu- 
liarities are  transmissible,  and  may  be  inherited  even  by  those  whose 
uric  acid  function  is  not  perceptibly  modified,  we  infer  that  uric  acid 
troubles  are  not  the  primary  cause  of  the  gouty  habit. 


CONCLUDING  PROPOSITIONS  319 

their  lymphatics.  It  is  still  a  question  whether  acute  goidy 
arthritis  is  due  to  mechanical  irritation  by  the  crystals,  or 
to  chemical  irritation  by  the  concentrated  solution  of  the 
sodium  biurate.*  Neither  the  latter  nor  uric  acid  itself  is 
toxic. 

Great  mechanical  irritation  such  as  would  set  up  inflam- 
mation is  not  a  necessary  feature  of  the  uratic  deposition. 
Perhaps  the  distinction  between  the  acutely  severe  and  the 
painless  form  is  in  a  great  measure  a  question  of  the  rate 
at  which  it  takes  place. 

2,2>-  The  extent  of  the  arthritis  associated  with  the  peri- 
articular swelling  is  matter  of  doubt.  Sir  W.  Wade's 
observations  go  far  towards  proving  that  there  is  much 
less  arthritis  than  had  hitherto  been  supposed — at  any  rate, 
that  the  pain  and  tenderness  have  not  their  seat  inside,  but 
outside  the  joint,  and  apparently  in  the  nerves  themselves. 

The  facts  observed  by  Sir  W.  Wade,  and  confirmed  by 
others  and  by  the  writer,  possess  great  theoretical  import- 
ance. 

34,  The  nervous  system  is  largely  concerned  in  all  the 
phases  of  gout  and  of  goutiness  ;  and  probably  it  also 
influences  their  mysterious  hereditary  transmission, 

35.  In  acute  gouty  arthritis  the  share  of  the  nervous 
system  is  variously  allotted  by  different  authorities. 

(a)  Some  assume  a  direct,  others  a  reflected  nervous  action, 
modifying  in  some  unexplained  way  the  intra-articular 
events. 

(6)  Sir  W.  Wade  has  originated  the  view  that  the  local 
gouty  attack  is  an  acute  neuritis,  due  to  the  local  action  of 
the  biurate  upon  the  nerves. 

(c)  The  writer  puts  a  different  interpretation  upon  Sir 
W.  Wade's  observed  facts,  and  would  regard  the  peri- 
articular nerve  complication  as  congestive,  and  (together 

*  C/.  p.  48. 


320  CONCLUDING  PROPOSITIONS 

with  the  accompanying  oedema)  as  reflected  from  the  irrita- 
tion by  the  biurate  of  the  intra-articular  nerve-endings. 

36.  Again,  the  induction  of  an  articular  seizure  by 
nervous  excitement  or  exhaustion  is  matter  of  every-day 
observation.  This  is  another  instance  of  the  instabihty  of 
the  organic  reactions,  which  is  pecuhar  to  the  gouty  state. 
If  the  larger  share  in  the  gouty  process  which  we  have 
claimed  for  the  organs  of  metabolism,  and  particularly  for 
the  liver,  really  belongs  to  them,  the  nervous  mechanism 
of  the  articular  paroxysm  might  be  explained.  The  local 
uratic  precipitation  might  be  the  result  of  an  acute  modifi- 
cation in  the  metabolism  of  these  organs,  which  are  known 
to  respond  with  remarkable  readiness  to  the  higher  nervous 
centres,  with  which  they  are  in  direct  sympathy. 

The  visceral  manifestations  of  goutiness  would  bear  an 
almost  identical  explanation. 

37.  The  phenomena  of  retrocedent  gotd  are  probably  to 
be  regarded  as  the  converse  of  this  nervous  process,  the 
reflex  action  beginning  at  the  periphery,  and  affecting  the 
nerve-centres  themselves,  as  in  gouty  encephalopathy,  or 
being  reflected  from  them  to  other  viscera. 

38.  The  participation  of  the  nervous  system  in  the 
slower  changes  which  constitute  goutiness  and  lead  up  to 
declared  gout  is  also  undeniable ;  but  very  different 
estimates  have  been  placed  upon  it.  The  discussion  of 
this  intricate  problem  cannot  be  renewed  here.  The  view 
which  has  been  advocated  in  these  pages  is  that  the 
nervous  system  influences  the  faulty  metabolism  in  the 
degree  in  which  it  suffers  itself  from  the  effects  of  a  per- 
verted nutrition.  In  this  limited  sense  gout  might  be 
termed  a  tropho-neurosis ;  but  it  is  not  here  implied  that 
the  process  originates  from  the  nervous  system  as  from 
some  independent  source,  external  to  the  constitutional 
disturbance :  the  nervous  system  merely  has  a  share  in 
propagating  the  latter. 


VIII. 

THE   TREATMENT   OF   GOUT   AND    OF 
GOUTINESS. 


CHAPTER   XXXVI. 

INTRODUCTORY  REMARKS. 

Various  reasons  invite  at  the  present  time  a  reconsidera- 
tion of  our  therapeutics.  In  the  type  and  in  the  incidence 
of  gout  definite  modifications  have  taken  place,  apparently 
correlated  with  the  altered  conditions  of  modern  life, 
which  tend  to  modify  constitutions.  Recent  advances  in 
pathology  have  also  called  in  question  previously  un- 
doubted principles  of  treatment.  Some  radical  innova- 
tions have  been  suggested.  And  lastly,  the  rapid  progress 
of  pharmacology  has  supplied  us  with  many  new  remedies, 
the  claims  of  which  need  to  be  considered.  Before  enter- 
ing upon  this  section  of  our  work,  a  few  general  remarks 
are  called  for. 

EMPIRICISM  AND  PATHOLOGY. 

A  systematic  analysis  of  the  varied  morbid  states  which 
have  been  included,  sometimes  without  sufficient  dis- 
tinction, under  the  term  '  gout '  was  a  necessary  pre- 
liminary  to  the   practical  objects    contemplated   in   this 

21 


EMPIRICISM  AND  PATHOLOGY 


work.  Between  the  pathological  and  clinical  aspect  of 
disease  and  its  therapeutical  aspect  there  is  a  close  rela- 
tion. In  gout,  where  much  remains  to  be  elucidated,  the 
uncertainties  of  pathology  are  reflected  in  therapeutics, 
and  fresh  theories  of  treatment  are  the  unavoidable  out- 
come of  each  new  pathological  departure. 

Long  before  the  dawn  of  pathology  empiricism  was  at 
work.  Human  life  has  ever  been  too  short  to  allow  the 
patient  to  wait,  or  the  physician  to  strive,  for  a  perfection 
of  knowledge  before  dealing  with  disease.  Indeed,  for 
the  greater  part  of  his  life,  the  physician  is  an  empiric 
ex  officio. 

Pure  empiricism  in  therapeutics  is  the  soil  in  which 
the  earliest  germs  of  pathology  are  sown  and  developed. 

Pathological  theories  are  the  upshot,  and  these  in  turn 
influence  practice.  Treatment  originally  empirical  is 
now  guided  by  theory.  Nowhere  is  this  mutual  relation 
more  marked  than  in  the  history  of  gout,  the  thera- 
peutics of  which  have  passed  through  the  most  varied  and 
arbitrary  phases  of  empiricism,  and  through  the  stage  of 
subservience  to  theory,  of  which  we  are  now  witnessing 
the  end. 

In  their  modern  developments  therapeutics  and  patho- 
logy are  more  closely  associated  than  ever.  Their  relation 
is  one  of  collaboration  ;  and  it  would  be  difficult  to  say 
which  contributes  the  larger  share. 

Pathological  facts  should  be  the  sole  guides  to  treat- 
ment. This  is  the  ideal  which  we  have  too  long  failed  to 
realize,  but  towards  the  attainment  of  which  progress  is 
being  made. 

Meanwhile,  in  some  directions  therapeutics  have 
advanced  to  the  stage  of  clinical  certainty ;  and  the 
•definiteness  in  the  therapeutic  results  has  become  a 
fulcrum    for   pathological    research,    and    a    standard   by 


PATHOLOGY  AND  THERAPEUTICS  323 

which  the  correctness  of  some  of  our  theoretical  views 
may  be  tested.  The  help  thus  derived  from  a  study  of 
the  treatment  of  gout  is  undoubted.  The  secret  of  the 
maze  may  often  be  solved  by  the  remedy.  When  it 
succeeds,  it  travels  through  the  intricate  route  along 
which  we  cannot  follow,  and  by  watching  its  operations 
we  obtain  some  clue  as  to  the  points  which  it  visits,  and 
as  to  the  mechanisms  which  it  may  set  in  motion. 

The  preceding  remarks  apply  to  all  forms  of  disease. 
In  the  case  of  gout  a  special  difficulty  had  to  be  dealt 
with  :  the  pathological  confusion  resulting  from  an  im- 
perfect nomenclature  threatened  to  complicate  the  study 
of  its  therapeutics.  Indeed,  the  confusion  which  even 
now  prevails  is  answerable  for  much  of  the  perplexing 
divergence  between  current  methods  of  practice.  A  dis- 
crimination between  such  essentially  different  conditions 
as  those  of  gout  and  goutiness  would  best  explain  how  an 
equal  success  should  have  been  reported  from  the  employ- 
ment of  opposite  measures.  The  conditions  alleged  to  be 
identical  have  much  less  in  common  than  the  mislead- 
ing identity  in  their  names  would  suggest.  They  cannot 
fairly  be  considered  under  the  same  heading,  and  in  the 
following  pages  they  will  be  dealt  with  separately. 

Our  inquiry  into  the  nature  of  gout  may  have  failed  in 
its  immediate  object,  but  it  will  not  have  been  barren  if  it 
has  warned  us  against  blindly  trusting  in  any  theory  as  a 
guide  to  treatment.  Meanwhile,  clinical  analysis  has 
made  it  clear  that  both  in  gout  and  in  goutiness  there  are 
numerous  varieties,  and  that,  indeed,  no  two  cases  are 
absolutely  alike.  Two  practical  principles  are  its  direct 
outcome :  '  Each  patient  has  an  individual  gout  of  his 
own,  for  which  an  individual  treatment  has  to  be  devised  ;' 
and,  above  all,  '  We  should  treat  the  patient  rather  than 
the  disease.' 


324        IS  GOUT  CURABLE?  ANCIENT  SCEPTICISM 

IS  GOUT  CURABLE,  AND  SHOULD  IT  BE  TREATED? 

A  REVIEW  OF  ANCIENT  AND  OF  MODERN 

SCEPTICISM. 

Scepticism  in  Antiquity. — Each  age  has  its  sceptics  in 
therapeutics  as  well  as  its  enthusiasts.  Lucian's  satirical 
poem,  TpayoiroSdypa,  part  of  which  is  here  given  in 
Sydenham's  Latin  translation,  teaches  us  the  form  taken 
by  the  scepticism  of  those  days,  and  its  cause. 

LUCIANI  IRRISIO  IN  MEDENTES  PODAGRA. 

Quis  invictam  me  dominam  dolorum 
Ignorat  Podagram  in  terra  mortalium  ? 
Quam  neque  f hurts  vapor placat, 
Neque  effusus  sanguis  aras  ad  incensas, 

Non  templum  divitiarwn  undique  suspensis  ornatum  donariis. 
Quam  neque  Apollo  medicamentis  expugnare  valet, 
Omnium  medicus  i?i  ccelo  deormn, 
Non  filius  Apollinis  doctissimus  ^sculapius. 
Fostquam  enim  enatum  est primum  hominibus  genus, 
Co?iantur  omnes  meam  elidere  potentiam., 
Miscentes  semper  medicamentorum  artificia. 
Alius  aliam  in  me  experitur  artem  : 
Teruni plantagines,  et  apia  mihi, 
Et  folia  lactucarum,  et  silvestrem  portulacam, 
Alii  marrubium,  alii potamogeitonem. 
Alii  urticas  terunt,  alii  Symphytum, 
Alii  lentes  afferunt  ex  palustribus  lectas. 
Alii  pastinacam  coctajn,  alii  folia  Persicorum, 
Hyoscyamum,  papaver,  cepas  agrestes,  mali  Punici  cortices, 
Psylliiwi,  thus,  radicejn  ellebori,  ?iiti'um, 
Foenuni  GrcBcum  cum  vino,  gyrine^n,  collamphacwn, 
Cyperissinam  gallam,  pollinem  hordeaceum, 
Brassicce  decoctce  folia,  gypsum  ex  garo, 
Stercora  montancB  caprce,  humanum  oletum, 
Farinas  fabarw7i,  florem  Asii  lapidis  ; 
Coquunt  rubetas,  mures-araneos,  lacertas,feles, 
Rarias,  hyce?tas,  tragelaphos,  vulpecnlas. 


LUCIA N'S  SATIRE  325 


Quale  metallum  non  exploratutn  est  mortalibus  ? 
Quis  non  succiis  ?  qua  lis  non  arborum  lachryjna  ? 
Animalium  quorumvis  ossa,  nervi,  pelles, 
Adeps,  sanguis,  medulla,  [urina,*]  stercus,  lac. 
Bibunt  alii  numero  quaterno  pharmacum, 
Alii  octono,  sed  septeno  plures. 
Alius  vero  bibens  hieram  purgaiur, 
Alius  incantaviejitis  impostoruni  deluditur, 
Jud(zus  aliurn  stultum  excantat  nactus  ; 
Alius  vero  remediwn  petit  ab  hirundinis  nido. 
Ego  auteni  his  otnnibus  plorare  impero. 
Et  facientibus  hcec,  atque  irritantibus  tne, 
Soleo  occurrere  multo  iracundior  ; 
lis  vero  qui  cogitant  nihil  adversum  mihi 
Benignant  adhibeo  mentem,  facilisque  fio. 

***** 
Lenem,  O  ubique  gentium  celebrata,  afferas  nobis  dolorein,  O 
Podagra, 
Levem,  facilem,  non  acutum,  brevem,  haud  scevientem, 
Tolerabilem,  facile  desinentem,  parum  validum,  ambulationes  nofi 
impedientem. 
Multi  sunt  modi  miserorum, 
Sed  exercitia  dolorum  et  cofisuetudo 
Podagricos  soletur. 
Ideoque  czquo  animo,  O  complices, 

Obliviscimini  dolorum : 
Si  ea  qucz  placet  non  fiunt, 
Tamen  etiam  prczter  spem  accidentibus  viam   invenire  solet 

Deus. 
Qiiivis  sustineat  Podagra  laborantium 
Deludi  et  derideri  ; 

Talis  enini  hujus  morbi  natura  est. 

This  was  essentially  a  therapeutical  scepticism.  Absurd 
and  useless  remedies  were  used,  and  the  scepticism  ex- 
pressed was  merely  a  keen  sense  of  their  uselessness.  On 
the   one   hand   a   countless   supply  of   useless  nostrums 


*  urina  om.  Syd. 


326  MODERN  SCEPTICISM 


praised  up  by  enthusiastic  empirics ;  on  the  other,  the 
cynically  expressed  hopelessness  of  the  sufferer.  All  this 
is  told  us  in  the  scathing  satire.  Scepticism,  then 
thoroughly  justified,  has  survived  into  modern  times,  and, 
to  a  modified  extent,  still  lingers  among  us  without  the 
same  excuse.  The  question  which  it  has  raised  must  be 
considered. 

Modern  scepticism,  whilst  doubting  the  efficacy  of 
remedies,  has  cast  doubt  also  upon  the  curability  of  the 
disease — nay,  even  upon  the  desirability  of  its  being 
treated.  Gout  is  perhaps  the  only  affection  concerning 
which  it  has  seriously  been  asked  whether  a  cure  was  to 
be  attempted  or  desired ;  and  this  question  suggests  that 
more  harm  than  good  may  sometimes  have  resulted  from 
the  attempt.  Such,  at  least,  was  the  opinion  of  Sydenham, 
who  did  not  hesitate  to  advocate  abstention. 

The  well-being  and  comfort  following  a  severe  storm  of 
gout  convey  a  suggestion  that  the  attack  is  beneficial.  In 
some  form  or  another  we  can  trace  this  idea  through 
history,  and  it  is  indicated  at  the  close  of  the  passage 
quoted  from  Lucian.  Sydenham  lent  to  it  the  support  of 
his  great  authority ;  he  regarded  the  fit  as  a  happy  event, 
a  clearing  of  the  blood  which  it  might  be  dangerous,  or  at 
any  rate  inadvisable,  in  any  way  to  check.  Among  the 
public  a  similar  view  seems  to  have  largely  prevailed. 

So  widespread  an  impression  can  hardly  have  arisen 
without  some  foundation.  We  are  far  from  subscribing 
to  the  theory  or  to  the  practice  in  question,  but  we  note 
in  passing  the  pathological  significance  of  any  partial 
relief  or  temporary  immunity  possibly  conferred.  If  the 
articular  attack  is  in  any  sense  curative,  how  great  must 
be  the  difference  between  it  and  the  morbid  condition 
which  it  remedies,  and  which  we  must  assume  to  be  the 
constitutional  state  of  goutiness  ! 


CURABILITY  OF  GOUT  327 

As  regards  the  curability  of  gout,  Sydenham's  somewhat 
gloomy  conclusions,  derived  from  personal  experience, 
have  perhaps  more  than  any  other  circumstance  encour- 
aged scepticism.  His  doctrine  of  non-interference,  com- 
pressed by  Cullen  into  a  well-known  utterance  praising 
the  virtues  of  '  patience  and  flannel,'  tended,  moreover, 
to  render  a  fair  trial  of  any  treatment  almost  impos- 
sible. 

Little  wonder  that  for  a  time  gout  suffered  neglect  at 
the  hands  of  the  profession.  The  undisguised  indepen- 
dence of  the  unrelieved  patient  found  a  counterpart  in  the 
apathy  of  the  physician  once  convinced  of  failure.  Scuda- 
more  tells  us  of  a  distinguished  physician  who  declined  to 
continue  his  attendance  on  a  patient  suffering  from  an 
acute  attack,  declaring  that  he  could  do  nothing  for  the 
gout. 

In  this  way  is  readily  explained  the  popularity  which 
has  been  enjoyed  by  various  quack  remedies ;  for,  as  Sir 
Dyce  Duckworth  remarks,  '  the  appeal  to  quack  remedies 
is  a  measure  of  our  failure.' 

The  present  attitude  is  one  of  compromise.  Absolute 
scepticism  in  therapeutics  is  a  thing  of  the  past.  Though 
we  have  ceased  to  be  credulous  as  to  the  alleged  virtues  of 
most  drugs,  the  claims  of  others  are  based  on  demonstra- 
tion. 

Among  modern  authorities  we  find  no  professed  sceptics. 
Garrod  distinctly  holds  that  '  gout  in  its  acute  form  is  as 
controllable  as  any  other  inflammatory  affection,'  and  that 
chronic  gout  may  be  relieved — at  least,  to  the  extent  of 
enabling  the  patient  to  enjoy  life.  And  others  have  con- 
curred in  the  same  opinions.  Sir  W.  Roberts,  however, 
whilst  providing  us  with  definite  ideas  as  to  the  chemistry 
of  gout,  has  expressed  doubt  as  to  the  value  of  some  of  the 
remedies  now  in  use.     Still,  he  is  far  from  endorsing  in 


328  THE  PATIENTS  VIEW  OF  TREATMENT 

principle  the  masterly  inactivity  of  Cullen,   or  even  the 
relative  inactivity  of  Sydenham. 

Our  own  answer  to  the  question  under  consideration  is  : 
'  Gout  is  curable,  but  some  of  its  worst  results  are  not.' 
If  our  aetiology  is  right,  if  gout  is  self-inflicted,  if  it  is  the 
outcome  of  absolute  or  relative  inactivity,  coupled  with 
over-indulgence — in  short,  a  manufactured  product  of 
civilization — it  is  certainly  preventable ;  it  may  even  be 
cured  after  its  onset.  Prior  to  its  earliest  warnings,  and 
for  some  time  afterwards,  the  remedy  is  in  our  own  hands- 
An  active  and  frugal  life  is  a  safe  preventive,  and  may 
often  be  a  cure. 

THE  PATIENT'S  VIEW  OF  GOUT  AND  OF  ITS 
TREATMENT. 

Few  popular  fallacies  have  been  longer  cherished  than  the 
notion  that  gout  was  a  harmless,  nay,  a  beneficial  affec- 
tion, to  be  envied  whilst  condoled  with  in  others,  and,  as 
Heberden  pithily  puts  it,  'to  be  rather  courted  than 
dreaded  by  patients  until  they  had  experienced  its  tor- 
ments.' Walpole  is  stated  to  have  faced  even  the  acute 
pain  of  gout  in  a  spirit  of  thankfulness,  regarding  it  as  a 
remedy  rather  than  a  disease.  But  the  time  is  past  when 
the  fashionable  malady  was  welcomed  with  pride  in  spite 
of  its  dangers.  The  evils  of  gout  are  obvious  and  great, 
its  privileges  purely  sentimental,  and  now  less  than  ever 
appreciated.  We  hear  less  of  the  social  dignity  of  gout ; 
we  sympathize  less,  perhaps,  with  its  mode  of  production ; 
we  are  less  reckless  in  inviting  its  risks,  which  have  now 
been  put  to  the  financial  test.  No  life  insurance  officer 
fails  to  scrutinize  the  life  and  the  family  history  of  appli- 
cants from  this  point  of  view.  In  truth,  in  no  other 
disease  are  higher  stakes  laid  by  those  who  court  it,  for 
the  lives  sacrificed  to  gout  are  usually  those  best  worth 


THE  PATIENT'S  VIEW  OF  TREATMENT  329 

preserving.  Gout,  in  a  word,  is  a  much  less  welcome 
visitor  than  it  has  been ;  and  the  diagnosis  of  gout,  when 
it  has  to  be  made,  is  more  often  received  with  disappoint- 
ment, or  even  resented. 

Treatment  may  always  be  viewed  from  two  sides — that  of 
the  physician,  and  that  of  the  patient.  Of  all  our  internal 
diseases,  there  is  probably  not  one  in  which  the  patient, 
whilst  racked  with  bodily  pain,  keeps  a  clearer  mental 
faculty,  and  exercises  a  keener  criticism  ;  and  the  treat- 
ment of  gout  has  thus  been  among  the  most  freely  debated 
in  the  whole  range  of  medicine.  The  sufferers,  themselves 
largely  responsible  for  the  origin  of  their  complaint,  readily 
take  an  active  part  also  in  its  management,  thereby  some- 
times checking  the  best  endeavours  for  their  relief.  In 
this  connection  Heberden  wisely  remarks :  '  The  gout 
should  not  be  considered  as  a  reproach  to  medical  prac- 
titioners till  they  are  permitted  to  attempt  a  cure  of  the 
disease,  or  until  they  can  find  gouty  patients  who  will 
follow  their  advice.' 

Among  the  gouty  are  many  distinguished  by  the  gifts  of 
the  mind,  by  mental  activity,  and  by  habits  of  close  study. 
Critics  such  as  these  were  not  likely  to  overlook  any  con- 
tradictions in  medical  theory  and  practice.  Their  scep- 
ticism was  fully  justified  so  long  as  no  serious  remedies 
were  employed  for  their  relief.  Sometimes,  however, 
when  at  a  later  date  efficacious  measures  have  been  re- 
commended, the  same  spirit  of  scepticism  has  prevented 
their  application. 

The  conflict  between  the  two  views  is  nowhere  so  per- 
plexing as  when  the  physician  himself  happens  to  be  the 
sufferer.  Even  to-day  we  meet  with  members  of  the  pro- 
fession who  prefer  the  disease  to  the  irksomeness  of  its 
cure.  They  are  the  exception,  whilst  the  name  is  legion 
of  those  physicians,  with  less  authority  than  Sydenham, 


330  THE  PATIENTS  VIEW  OF  TREATMENT 

but  likewise  martyrs  to  the  gout,  who  are  strong  believers 
in  treatment,  and  who  on  no  account  would  approve  in 
their  own  case  of  the  adoption  of  an  expectant  plan. 

Lastly,  idiosyncrasy  adds  many  a  complication.  The 
patient  who  is  an  expert  in  the  knowledge  of  his  own 
familiar  symptoms,  and  of  the  influence  of  various 
remedies,  is  often  fully  aware  of  the  peculiar  effect  which 
some  of  them  may  take  upon  him.  In  short,  the  con- 
firmed gouty  subject  entertains  more  commonly  than  any 
other  patient  settled  views  as  to  treatment,  and  the 
physician  may  be  wise  in  not  too  lightly  disregarding  his 
opinion. 


CHAPTER  XXXVII. 

THE  PRINCIPLES  OF  TREATMENT,  AND  THE 

THERAPEUTIC    INDICATIONS    IN 

GOUT  AND  GOUTINESS. 

THE  VARIOUS  MODES  OF  TREATMENT. 

The  treatment  of  gout  may  be  classified  as  medicinal, 
dietetic,  and  hygienic.  Of  these  three  varieties  the  first 
is  that  of  which  we  can  speak  with  least  certainty,  and 
also  that  most  apt  to  vary  with  the  subject  or  the  stage 
of  the  affection.  A  review  of  the  medicinal  agents  and 
of  other  therapeutic  measures,  and  of  their  mode  of 
employment  in  gout,  will  form  a  necessary  introduction 
to  this  part.  The  treatment  of  acute  gouty  arthritis,  of 
chronic  gouty  arthritis,  and  of  retrocedent  gout,  will  be 
considered  ;  and  we  shall  deal  finally  with  the  treatment 
of  goutiness,  with  that  of  its  chief  manifestations,  and  with 
its  prophylaxis. 

THE  PROSPECTS  OF  TREATMENT  AT  VARIOUS 
ST  A  GES. 

Some  cases  of  inherited  gout,  beginning  in  youth  and 
running  through  a  long  life,  present  us  with  an  almost 
complete  series  of  the  phases  of  the  affection,  including 
the  early  symptoms  of  goutiness,  the  acute  attacks  which 


332   PROSPECTS  OF  TREATMENT  AT  VARIOUS  STAGES 

may  be  complicated  with  retrocessions,  and  chronic  gout, 
with  its  arthritic  changes  and  visceral  symptoms,  and  with 
its  characteristic  fluctuations  under  the  influence  of  the 
seasons. 

The  longer  the  gouty  tendency  has  existed,  the  more 
does  it  become  confirmed  and  intensified :  not  that  there 
is  more  of  the  acute  character  about  it,  but  because  the 
whole  constitution  is  more  inveterately  gouty.  In  a  few 
cases,  a  maximum  may  be  touched  about  the  period  of 
middle  life,  and  although  gout  may  never  be  absolutely 
thrown  off,  it  may  gradually  need  less  of  the  physician's 
attention  and  of  any  systematic  treatment  except  the 
hygienic.  With  increasing  age  it  may  be  almost  regarded 
as  obsolescent. 

In  gout  the  results  of  treatment  are  often  difficult  to 
estimate.  This  is  due  to  the  waviness,  to  the  flux  and 
reflux  in  the  incidents  of  the  affection,  which,  it  would 
seem,  spontaneously  tends  to  periodical  or  to  irregular 
aggravations  and  remissions. 

Success,  during  the  earlier  stages,  will  greatly  depend 
on  the  adequacy  of  the  measures  recommended,  and  yet 
more  on  the  thoroughness  with  which  the  patient  lends 
himself  to  their  application.  With  sufficient  care,  and  in 
the  absence  of  accidental  complications,  the  worst  evils 
of  gout  might  be  indefinitely  staved  off. 

So  long,  however,  as  the  gouty  tendency  prevails,  any 
unlucky  circumstance,  such  as  a  surgical  injury,  which 
may  suddenly  remove  the  protecting  effect  of  regular  and 
full  exercise,  may  lead  to  an  outbreak.  This  danger  may 
be  partly  met  by  forethought  and  by  judicious  manage- 
ment of  the  patient  thus  unhappily  condemned  to  mus- 
cular inactivity. 

It  is  in  the  earhest  stage  that  the  best  results  can  be 
obtained.     The  advantages  of  a  systematic  preventive  treat- 


PROSPECTS  OF  TREATMENT  AT  VARIOUS  STAGES  333 


ment  should  be  secured  at  the  eariiest  age  for  those 
children  whose  family  history  points  to  a  likelihood  of 
gout  being  ultimately  developed  in  them.  If  their  delicacy 
be  successfully  combated,  much  of  the  tendency  to  vis- 
ceral changes  described  in  connection  with  goutiness  may 
be  held  in  check,  and  the  serious  visceral  consequences 
apt  to  result  from  their  continuance  will  be  prevented, 
with  considerable  improvement  in  the  prospect  of  life. 
It  is  clear,  however,  that  nothing  can  raise  the  resistance 
of  the  subjects  inheriting  a  tendency  to  gout  to  the  level 
of  that  of  the  robust.  The  avoidance  of  gout  must  be 
for  them  a  lifelong  study.  In  the  words  of  Sydenham  : 
*  As  for  a  radical  cure,  one  altogether  perfect,  and  one 
whereby  the  patient  might  be  freed  from  even  the  disposi- 
tion to  the  disease — this  lies,  like  Truth,  at  the  bottom  of  a 
well ;  and  so  deep  is  it  in  the  innermost  recesses  of  Nature 
that  I  know  not  when  or  by  whom  it  will  be  brought 
forward  into  light  of  day.' 


THE  THERAPEUTIC  INDICATIONS  IN  GOUT  AND 
GOUTINESS. 

The  Remote  '  Causal '  Indication. — As  in  all  other  affec- 
tions, the  indications  for  treatment  are  based  upon  a 
consideration  of  the  cause,  and  a  study  of  the  phenomena 
and  of  the  symptoms.  Both  gout  and  goutiness  differ, 
however,  from  the  majority  of  ailments  by  possessing, 
in  addition  to  the  stage  of  activity,  a  prior  stage  of 
latency,  or  stage  of  evolution. 

The  original  cause  of  gout  was  correctly  appreciated  by 
Greek  and  Roman  physicians.  This  portion  of  their 
therapeutics  leaves  little  room  for  improvement.  It 
includes  such  orthodox  precepts  as  the  avoidance  of  all 
excesses,  a  regular  and  frugal  diet,  exercise,  etc.     These 


334  THERAPEUTIC  INDICATIONS  IN  GOUT 

remote  causal  indications,  sketched  out  for  us  by  our 
distant  predecessors,  will  be  our  guide  in  the  subject  of 
hygiene  and  of  diet.  They  are  identical  with  the  indica- 
tions oi preventive  treatment.  In  this  resides  their  greatest 
practical  importance. 

The  Proximate  Causal  Indications. — Declared  gout  also 
claims  to  be  treated  on  the  rational  basis  of  its  immediate 
causation.  Here  we  realize  the  helplessness  of  our 
pathology.  With  every  change  in  the  setiological  theories 
of  gout  the  methods  of  treatment  have  presented  cor- 
responding oscillations,  and  extreme  and  exclusive  measures 
have  been  their  outcome.  We  are  still  imperfectly  ac- 
quainted with  the  aetiology,  and  we  cannot  yet  boast  of 
having  fulfilled  the  causal  indication  in  the  treatment 
of  gout. 

The  objective  indications  are  furnished  by  a  clinical  study 
of  the  phenomena  themselves,  irrespective  of  their  cause. 
Accurate  observations,  clinical  instinct  and  experience, 
and  practical  wisdom  should  be  sufficient  guides.  Yet  in 
framing  their  treatment  of  the  obvious  phenomena 
physicians  have  not  wholly  succeeded  in  divesting  them- 
selves of  their  theoretical  notions  as  to  causation. 
Clinical  indications  have  not  always  been  followed  with 
an  open  mind,  and  on  the  pure  lines  of  common-sense. 
Pathological  views  as  to  the  nature  of  inflammation,  apart 
from  gout,  have  also  cast  their  shadow  upon  the  practical 
treatment,  which  otherwise  might  have  presented  greater 
uniformity. 

These  shortcomings  are  illustrated  by  the  history  of 
the  topical  treatment  of  gout,  which  presents  almost 
as  great  a  variety  as  that  of  its  internal  medication. 
Every  kind  of  agent  has  been  prescribed  and  applied — 
heat  and  cold ;  the  cautery  or  moxa  and  ice ;  leeching 
and  scarifying  ;  bhstering  and  astringents ;  soothing  ap- 


SPECIAL  INDICATIONS  IN  GOUT  AND  GOUTINESS  335 

plications,  such  as  oil,  and  stimulating  lotions ;  so  divergent 
were  the  views  which  have  been  held  of  the  nature  of 
the  local  trouble. 

Symptomatic  Indications  of  Treatment. — Lastly,  under 
this  heading  would  naturally  fall  the  indications  arising 
out  of  the  patient's  conscious  feelings,  and  also  those  derived 
from  obvious  clinical  features,  such  as  aspect,  fever,  and 
the  various  constitutional  states.  These  indications  are 
of  special  importance  in  connection  with  goutiness,  many 
of  the  manifestations  of  which  are  rather  symptomatic 
than  objective ;  but  in  gout  also  they  correspond  to  a 
definite  part  of  our  therapeutics. 


THE  SPECIAL  INDICATIONS  IN  GOUT  AND  GOUTINESS. 

Sydenham's  ideas  of  the  therapeutical  indications  were 
governed  by  his  pathological  views  :  'In  respect  to  the 
treatment,  if  we  look  to  the  humours  themselves,  and  the 
indigestion  from  which  they  arise,  it  seems  at  first  that 
we  have  to  evacuate  the  aforesaid  humours,  and  to  guard 
against  their  increase  by  strengthening  the  concoction, 
which  is  only  what  is  to  be  done  in  all  humoral  com- 
plaints. In  gout,  however,  it  seems  as  if  it  were  the 
prerogative  of  Nature  to  exterminate  the  peccant  matter 
after  her  own  fashion,  to  deposit  it  in  the  joints,  and 
afterwards  to  void  it  by  insensible  perspiration.  In  gout, 
too,  but  three  methods  have  been  proposed  for  the 
ejection  of  the  causa  continens — bleeding,  purging,  sweating. 
Now,  none  of  these  succeed.' 

Garrod's  identification  of  uric  acid  as  the  chief  part 
of  the  materia  peccans  has  clearly  defined  the  indica- 
tions. In  dealing  with  uric  acid  as  the  alleged  basis 
of  gout,  three  lines  of  treatment  lie  before  us — the  pre- 
ventive, the   eliminative,   and   the    antidotal ;   and   these 


336  SPECIAL  INDICATIONS  IN  GOUT  AND  GOUTINESS 

we  shall  have  to  follow  out  in  connection  with  goutiness, 
and  with  acute  and  chronic  gout,  whilst  the  hygienic  and 
prophylactic  treatment  to  which  we  have  referred  meets 
the  indication  of  the  remote  causation  of  gout. 

In  goutiness  or  threatening  gout  the  leading  indications 
for  treatment  are  supplied  by  the  acidity,  by  the  lithaemia, 
and  by  the  inertia  of  the  excretory  functions ;  and  the 
same  apply  also  to  the  preventive  treatment  of  gout.  On 
all  these  points,  except  in  relation  to  acidity,  our  practice 
differs  from  that  of  Sydenham.  We  should  promote 
free  action  of  the  liver,  of  the  bowel,  of  the  skin,  and 
of  the  kidney,  as  well  as  obviate  the  acidity.  The  manner 
in  which  these  indications  are  to  be  carried  out  will  be 
explained  further  on. 

Meanwhile,  the  setiological  factor  should  not  be  over- 
looked, and  if  gout  is  rightly  to  be  traced  to  a  deficient 
activity  of  the  oxidizing  processes,  the  practical  conclu- 
sions are  obvious. 

In  acute  gout  the  indications  are  local  and  constitutional. 
Our  ignorance  of  the  mechanism  of  the  attack,  and  the 
unaccountable  manner  in  which  metastasis  may  occur 
at  times,  limit  our  action.  Of  one  thing  we  are  sure — 
that  a  gradtial  relief  of  the  gouty  symptoms  by  mild 
measures  is  never  attended  by  evil  complications,  but 
that  their  sudden  repression,  particularly  by  external 
applications,  has  its  risks. 

Local  pain  should,  if  possible,  be  mitigated  by  local 
treatment.  Its  relief  by  strong  sedatives  is  not  at  present 
available,  unless  colchicum  be  classed  among  the  latter. 
Opium  and  morphia  are  contra-indicated,  since  they  check 
the  secretions. 

The  swelling  and  arthritis  are  meanwhile  relieved  by  the 
internal  medication,  and  by  those  local  measures  which 
allay  the  pain. 


SPECIAL  INDICATIONS  IN  GOUT  AND  GOUTINESS  337 

The  constitutional  indication  connected  with  uric  acid 
is  fulfilled  by  the  derivative  treatment  directed  to  bowel, 
kidney,  and  skin. 

Lastly,  the  other  aspect  of  the  setiological  treatment 
is  carried  by  the  restriction  of  the  diet  to  those  foods 
which  may  be  digested  without  effort,  without  acidity, 
and  without  adding  much  nitrogen  to  the  accumulated 
excess. 

The  chronic  stages  of  gout  are  to  be  managed  on  almost 
identical  lines,  both  as  regards  medicinal  treatment  and 
hygiene.  Unhappily,  the  capacity  for  movement  is  often 
greatly  restricted,  but  we  now  possess  fairly  good  substi- 
tutes for  active  exercise  in  passive  movement,  massage, 
and  resistance  movements. 

The  local  treatment  of  tophaceous  gout  would  aim  at  the 
removal  of  the  accumulations,  and  particularly  at  checking 
their  growth.  Both  these  ends  are  difficult  to  secure. 
Surgical  interference  has  not  hitherto  had  much  success. 
The  solvent  treatment  by  alkaline  applications  meets  with 
more  approval,  and  is  undeniably  sometimes  of  use.  The 
future  developments  of  electricity  may  perhaps  yield  better 
results  from  a  cautious  application  of  the  principles  of 
electrolysis  than  from  any  other  method.  Our  most 
anxious  care  should  be  to  preserve  as  much  motion  as 
possible  without  setting  up  dangerous  irritation  in  the 
joint. 

In  gouty  cachexia,  and  in  the  complications,  cardiac,  renal, 
diabetic,  etc.,  of  chronic  gout  and  of  goutiness,  fresh 
indications  are  superadded  to  those  special  to  gout.  There 
are  stages  in  advanced  gout  and  in  its  organic  conse- 
quences in  which  all  hope  of  amendment  must  be 
abandoned,  and.  palliative  treatment  only  remains.  The 
earlier  periods,  when  the  articular  disease  is  not  compli- 
cated with  visceral  degeneracy,  are  more  promising. 

22 


338  SPECIAL  INDICATIONS  IN  GOUT  AND  GOUTINESS 

The  indications  of  preventive  treatment  have  been  sketched 
out  in  the  foregoing;  they  apply  with  special  force  to 
the  management  of  the  progeny  of  gouty  parents.  Child- 
hood and  youth  are  the  time  when  an  impression  can  be 
made  upon  the  inherited  weakness,  and  the  measures  of 
hygiene  which  have  been  advocated  in  gout  and  goutiness 
can  be  carried  out  with  the  most  beneficial  results. 


CHAPTER  XXXVIII. 
THE  THERAPEUTIC   METHODS  AND  AGENTS. 

THE  EVACUANT  METHODS.— I.  EMETICS  AND 
PURGATIVES. 

Emetics. — The  administration  of  emetics  for  gout,  apart 
from  its  bronchial  or  gastric  complications,  has  fallen  into 
disuse,  and  is  not  likely  to  be  revived.  Any  office  they 
might  have  fulfilled  is  well  and  easily  accomplished  by 
other  means. 

Purgatives. — Properly  handled  there  is  no  better  method 
for  the  relief  of  gout  and  goutiness  than  gentle  purgation. 
This  had  been  recognised  by  some  of  the  ancients. 
Sydenham  gives  for  his  strong  disapproval  of  it  reasons 
which  are  full  of  instruction.*     The  paradox  of  his  adverse 

*  '  Then  as  to  any  catharsis,  either  above  or  below,  we  must  re- 
member that  it  is  the  inviolable  rule  of  Nature,  interwoven  with  the 
essentials  of  the  present  disease,  to  throw  the  peccant  matter  upon 
the  joints.  If  so,  all  that  can  be  done  by  purges  or  vomits  is  to  throw 
what  Nature  would  ingest  through  the  extremities  into  the  blood. 
Hence  it  happens  that  what  was  meant  for  the  joints,  takes  hold  of 
one  of  the  viscera  ;  then  the  patient's  life  is  in  danger.  .  .  . 

'  Sure  am  I  that  all  purging,  mild  or  sharp,  intended  to  relieve  the 
joints  is  mostly  injurious,  whether  it  be  during  a  fit,  to  diminish  the 
peccant  matter  ;  at  the  end  of  one,  to  dissipate  the  remnants  of  the 
disease  ;  or  during  an  intermission,  to  guard  against  the  occurrence 
of  one.  .   .  . 

'  In  the  first  place,  if  given  during  the  fit,  they  interrupt  the  work 
of  Nature.  .  .  .  A/iter  a  fit,  a  purge  should  perhaps  be  given  to  work 
off  the  remains  of  the  disease.    It  will  just  bring  on  a  fresh  one,  equally 


340  THE  EVACUANT  METHODS 

attitude  is  rendered  more  striking  by  the  following  ad- 
mission :  '  Nevertheless,  this  method,  bad  and  mischievous 
as  it  is,  has  made  the  reputation  of  many  empirics,  who, 
nevertheless,  have  made  a  secret  of  the  purge  they  use. 
For  it  must  be  noted  that  whilst  the  catharsis  goes  on, 
the  patient  either  suffers  not  at  all  or  very  slightly  ;  and 
provided  that  it  can  be  kept  on  for  a  few  days,  if  no  fresh 
fit  supervene,  the  original  one  will  go  off.  Sooner,  how- 
ever, or  later,  he  will  pay  a  tremendous  penalty  arising 
from  the  disorder  into  which  Nature  has  been  forced  head- 
long by  the  aforesaid  agitation  of  the  humours.' 

To  differ  from  Sydenham  is  less  unsafe  when  we  find 
his  opinion  at  variance  with  his  observations.  Our  object 
is  to  keep  the  materia  peccans  from  the  joints,  and  to 
protect  them  from  its  irritating  effects ;  and  in  carrying 
out  that  endeavour  no  time  is  to  be  lost.  Though  it  is 
now  generally  understood  that  the  disease  cannot  be  cut 
short  even  by  excessive  purgation,  and  that  great  harm, 
nay,  danger,  may  arise  from  this  form  of  jugulant  treat- 
ment, moderate  derivation  through  the  intestine  is  the 
most  effectual  means  at  our  disposal.  The  amount  of 
benefit  to  be  secured  will  greatly  depend  on  the  way  in 
which  this  indication  is  carried  out. 

Purgation  viewed  as  Part  of  the  Hepatic  Treatment. — The 
mild  initial  purgation  is  in  reality  a  first  instalment,  which 
needs  to  be  followed  up,  in  the  '  hepatic  '  treatment  of 
acute  gout.  The  drugs  now  in  use  carry  out  this  essential 
indication  in  a  manner  not  attained  in  the  days  of  Syden- 
ham. This  may  explain  the  less  favourable  results  of 
the  purgative  treatment  in  his  hands. 

bad.  .  .  .     This  I   have  found  in  my  own  person.  .  .  .     Lastly,  in 

respect  to  purging  at  certain  intervals,  whilst  the  health  is  good  .  .  . 

it  must  still  bring  on  one,  and  that  for  reasons  already  given.  If 
it  fail  in  doing  this  it  by  no  means  carries  off  the  disease.' 


THE  E  VACUA  NT  METHODS  341 

//.  BLEEDING. 
This  ancient  method  of  ehmination  is  not  now  regarded 
with  favour,  and  is  recommended  neither  by  the  proba- 
bihties  nor  by  the  results  of  its  employment.  Others  besides 
Sydenham  had  spoken  adversely  of  its  action  in  gout ;  the 
latter,  however,  recognised  it  as  part  of  the  treatment  of 
the  complications  of  pneumonia  and  of  congestion.  At  the 
present  time  the  indication  for  venesection  arises  less  often 
than  ever  before.  Local  depletion  is  also  in  most  cases 
undesirable  and  unnecessary. 

III.  DIURETICS. 
Derivation  by  diuresis  is,  from  the  standpoint  of  the 
uric  acid  theory,  the  most  rational  of  methods.  The 
obvious  requirement  is  to  eliminate  the  uric  acid  through 
its  normal  channel  of  excretion.  In  practice  the  indica- 
tion of  increasing  the  flow  and  the  solvent  power  of 
urine  is  always  carried  out  by  the  substitution  of  a  fluid 
diet  for  solid  alimentation.  Colchicum  also  frequently 
acts  as  a  diuretic.  The  use  of  the  stronger  diuretics  is 
not,  however,  desirable  ;  some  of  them,  such  as  digitalis, 
which  raise  the  blood-pressure,  are  contra-indicated.  The 
kidney  itself  is  in  a  tender  state,  and  should  not  be  over 
stimulated.  No  risk  of  this  kind  attaches  to  the  use  of 
the  alkaline  salts  of  the  organic  acids,  and  particularly 
to  the  bicarbonate,  citrate,  tartrate,  and  acetate  of 
potassium.  They  possess  also  the  advantage  of  rendering 
the  urine  less  irritating  to  the  kidney,  whilst  promoting 
the  solubility  of  urates. 

IV.  DIAPHORETICS. 

Diaphoresis,  a  much  less  powerful  method  of  derivation 
than  those  which  we   have  just  sketched,  is,   like  other 


342  THE  EVACUANT  METHODS 

agencies  which  effect  httle  at  any  one  time,  but  much  by 
their  continued  action,  eminently  suited  to  the  treatment 
of  goutiness,  and  of  the  subacute  gouty  state.  Sydenham 
recognised  its  value  in  the  intestinal  complications :  '  If, 
notwithstanding  the  laudanum  and  the  exercise  (the  first 
remedy  to  which  we  must  resort  in  diarrhoea),  the  bowels 
be  still  purged,  and  the  purging  be  accompanied  with 
gripes,  etc.,  the  only  remedy  known  to  me  is  a  sweat, 
brought  on  by  the  appropriate  medicines.  ...  In  this 
way  I  cured  myself,  some  years  ago,  after  I  had  impru- 
dently thrown  myself  in  the  way  of  danger  by  having 
taken  cold  water  as  my  ordinary  drink,  and  that  after  I 
had  sought  help  from  cordials  and  astringents  in  vain.' 

Diaphoresis  is  also  of  great  service  in  acute  gout  so  long 
as,  by  a  proportionately  liberal  supply  of  fluids,  the  urine 
is  kept  thoroughly  diluted.  Indeed,  it  fulfils  a  valuable 
office  in  connection  with  acute  arthritis  by  relaxing  the 
arterioles  of  the  skin,  and  considerably  lowering  blood-pres- 
sure. Theoretical  objections  probably  explain  Sydenham's 
distrust  of  its  use  : 

'  The  evacuation  of  the  peccant  matter  by  sweats, 
although  less  mischievous  than  the  other  two  forms,  is 
still  prejudicial.  .  .  .  Hence  in  gout,  as  in  all  other 
diseases  where  the  sweats  .  .  .  are  forced  rather  than 
natural,  it  is  very  dangerous  to  bring  them  on  too 
violently,  and  solicit  them  beyond  that  degree  of  con- 
coction to  which  the  humours  requiring  an  elimination 
have  arrived  of  their  own  accord.  So  teaches  Hippo- 
crates :  "  Cocta  non  cruda,  sunt  movenda  et  medicanda."  ' 

We  agree  with  this  caution.  Little  could  be  gained 
by  excessive  diaphoresis  to  compensate  for  the  lowering 
effect  on  the  patient ;  but  its  moderate  degrees  are  a 
source  of  comfort,  and  truly  beneficial. 


THE  ANTIDOTAL  OR  NEUTRALIZING  METHOD     343 

THE  ANTIDOTAL  OR  NEUTRALIZING  METHOD. 

This  indication  was  clearly  perceived  by  all  humoralists, 
but  their  erroneous  conception  of  the  nature  of  the  offend- 
ing matter  defeated  their  intentions.  Sydenham's  peculiar 
views  as  to  its  proper  disposal  led  him  into  the  following 
dilemma : 

'  If  evacuants  are  out  of  place  in  gout,  what  are  the 
indications  of  treatment  ?  Two  points  are  most  particu- 
larly to  be  considered.  The  first  is  the  causa  antecedens, 
or  the  ingestion  of  the  humours  arising  from  a  defect  of 
spirits.  The  other  is  the  causa  continens,  or  the  heat  and 
exaestuation  of  the  same,  when,  from  their  prolonged 
delay  in  the  body  (a  delay  arising  from  the  aforesaid 
inconcoction),  they  have  become  putrid  and  acrid.  These 
two  are  as  far  as  the  poles  asunder.  What  helps  one 
hurts  the  other.     Hence  the  difficulty  of  treatment.' 

The  progress  of  chemistry,  and  the  identification  as 
part  of  the  materia  peccans  of  an  excess  of  acid,  and 
specially  of  uric  acid,  have  solved  this  dilemma,  and 
rendered  possible  a  rational  application  of  the  antidotal 
method.  The  latter,  in  association  with  the  uric  acid 
theory,  has  claimed  ever  since  growing  and  almost 
exclusive  attention. 

The  alkaline  treatment  alluded  to  above  (c/.  p.  341)  will 
be  further  considered  later  on.  Sir  W.  Roberts  has  shown 
that  some  of  the  chemical  activities  which  had  been  attri- 
buted to  the  salts  of  the  alkaline  metals  are  imaginary. 
Meanwhile,  as  though  to  remind  us  by  a  reductio  ad 
absurdum  that  the  neutralizing  and  solvent  treatment  is 
only  a  secondary  indication,  organic  substances  of  great 
alkalizing  power  have  lately  been  tried,  which,  had  they 
proved  sufficiently  stable,  might  have  produced  in  the 
economy  results  less  desirable  than  the  mere  solution  of 


344         THE  PREVENTIVE  AND  LOCAL  METHODS 

uratic  deposits.     To  these  organic  solvents,  we  shall  make 
further  reference. 

It  has  happily  been  shown  that  alkalies  are  not  the  only 
antidotes  of  uratic  gout,  and  that  the  precipitation,  and 
even  the  formation,  of  uric  acid  may  be  to  a  certain  extent 
controlled  by  other  checks  than  that  of  an  alkaline  reaction. 

THE  PREVENTIVE  METHOD. 

This  is  the  absolutely  rational  method,  easier  to  recom- 
mend than  to  adopt.  To  obviate  the  production  of  an 
excess  of  uric  acid  and  of  acidity,  and  a  precipitation  of 
the  former,  diet  and  hygiene  are  the  direct  means,  and 
upon  them  we  shall  dwell  in  due  course. 

THE  LOCAL  METHODS. 

The  practical  aspects  of  local  treatment  will  be  dealt 
with  in  subsequent  chapters,  and  call  for  few  remarks  at 
this  stage. 

Warmth  and  Cold. — The  simple  clinical  experiment  con- 
stantly performed  in  the  test-tube — that  of  dissolving  the 
uratic  sediment  by  gentle  heat — might  almost  be  adduced 
an  an  object-lesson  in  therapeutics.  Moderate  and  equable 
warmth  is  of  undoubted  value  in  the  treatment  of  gout, 
and  a  source  of  comfort ;  still,  it  does  not  appear  that 
warmth  is  in  itself  curative,  nor  is  it  strictly  preventive. 
At  any  rate,  experience  does  not  justify  the  conclusion  that 
coldi  per  se  will  lead  to  gout. 

Sir  A.  Garrod,  however,  believes  in  a  local  predisposing 
influence  of  cold.  Tophi  would  attack  the  ears  because 
much  exposed  to  cold  ;  whilst  those  of  women  would  suffer 
much  less  because  more  protected.  Again,  the  toes  and 
the  knees  would  be  liable  to  gout  because  often  cold ;  the 
hips  would  remain  exempt  because  sharing  in  the  tempera- 


THE  LOCAL  METHODS  345 

ture  of  the  trunk.  The  practical  conclusions  to  be  drawn 
from  these  facts  are  obvious. 

Anodyne  applications  are  the  main  indication  for  the  relief 
of  pain.  No  objection  can  be  raised  against  their  help, 
which  is  increased  by  warmth. 

Resolvents  and  Astringents. — The  alkaline  applications 
are  the  representatives  of  the  first  of  these  groups,  and 
when  of  suitable  strength  and  composition,  they  are  bene- 
ficial, both  in  acute  gout  and,  with  a  special  view  to  their 
solvent  action,  in  tophaceous  gout.  Astringents  need 
delicate  handling.  They  answer  best  in  combination  with 
anodynes,  and  moisture. 

Local  stimulants  have  little  to  recommend  them  in  the 
treatment  of  gout  beyond  the  fact  that  some  patients  find 
relief  in  their  application,  and  believe  in  them. 

Local  depletives  and  revulsants,  such  as  leeching,  scari- 
fj'ing  and  blistering,  on  the  one  hand,  the  actual  cautery 
and  the  moxa,  or  immersion  into  cold  water,  on  the  other, 
have  ceased  to  form  part  of  our  therapeutic  methods. 


CHAPTER  XXXIX. 
THE  MEDICINAL  AGENTS.— COLCHICUM. 

HISTORY  AND  GENERAL  PROPERTIES 
OF  COLCHICUM. 

The  history  of  the  medicinal  treatment  of  gout  begins 
in  earnest  about  580  a.d.  with  the  introduction  by 
Alexander  of  Tralles  of  the  drug  termed  '  hermodactyl,' 
perhaps  identical  with  that  derived  from  the  East  in  more 
modern  times,  and  regarded  by  Pereira  as  having  consisted 
of  the  corms  of  some  species  of  Colchicum  autumnale,  and 
by  others  as  having  been  a  variety  of  Colchicum  variegatum. 
Hermodactyl  was  freely  employed  during  the  Middle  Ages 
by  the  great  Arab  physicians  (Avicenna,  Serapion,  etc,)- 
We  may  infer  that  it  partook,  though  in  a  milder  degree, 
of  the  properties  of  the  drug  now  in  use.  On  this  assump- 
tion, the  interval  which  may  be  termed  the  colchicum 
period  would  have  been  a  very  long  one ;  but  the  more 
limited  period  of  the  employment  of  Colchicum  autumnale 
and  of  its  great  vogue  was  that  of  the  fifty  years  which 
followed  Storck's  original  communication  :  it  is  identified 
with  the  names  of  Home,  Armstrong,  Scudamore,  Williams, 
and  others. 

Before  Storck  had  the  boldness,  in  1763,  to  try  its 
effects  in  his  own  person  and  in  that  of  patients  apparently 
hopelessly  stricken,  Colchicum  autumnale  had  been  regarded 


HISTORY  AND  PROPERTIES  OF  COLCHICUM        347 

as  a  dangerous  poison.  Since  then  it  has  often  been  the 
subject  of  experimental  study,  and  its  cHnical  employment 
has  afforded  continual  opportunities  for  a  discovery  of  the 
secret  of  its  power,  but  in  vain.  Our  knowledge  does  not 
extend  much  beyond  its  elementary  pharmacology.  The 
dried  corms  and  seeds  of  the  meadow  saffron  contain — 
besides  tannic  and  gallic  acids,  starch,  sugar,  gum,  etc. 
— an  amorphous,  yellowish,  bitter  alkaloid,  colchicine, 
CivHigNOs,  which  is  readily  soluble  in  water  and  in 
spirit. 

According  to  Mitchell  Bruce,*  colchicine  depresses  the 
convolutions  and  the  spinal  cord,  causing  loss  of  sensi- 
bility and  of  consciousness,  and  diminished  reflex  excita- 
bility ;  the  peripheral  sensory  nerves  being  also  paralyzed, 
whilst  the  motor  nerves  and  the  muscles  are  unaffected. 
The  activity  of  the  respiratory  centre  is  lowered,  so  that 
death  occurs  by  asphyxia,  and  the  heart  weakened,  so  that 
the  pulse  may  become  intermittent,  perhaps  as  a  disturb- 
ance secondary  to  that  of  the  respiration ;  the  skin  perspires, 
and  the  amount  of  urine  is  diminished,t  but  '  the  uric  acid, 
and  probably  the  urea,  are  increased  in  quantity,'  the 
kidneys  being  found  hypersemic  after  death.  As  a  gastro- 
intestinal irritant,  colchicum  sets  up  vomiting  and  purging, 
the  stools  being  bilious  in  character. 

It  is  remarkable  that  our  knowledge  of  the  value  of  the 
drug  should  have  come  so  late,  and  that  it  should  have 
remained  empirical.  No  less  striking  is  the  fact  that  the 
modern  growth  of  chemistry  and  of  pharmacology,  which 
have  furnished  us  with  new  remedies  of  great  efficacy  in 
some    other    ailments,    should    have    left    colchicum    in 

*  '  Materia  Medica  and  Therapeutics,'  p.  398,  1891. 

t  Dr.  M.  Bruce  informs  me  since  these  statements  were  written  that 
he  has  repeatedly  observed  considerable  diuresis  coinciding  with  the 
rapid  relief  of  the  acute  attack  by  colchicum. 


348        HISTORY  AND  PROPERTIES  OF  COLCHICUM 

undivided  possession  of  its  reputation  as  the  specific  in 
gout. 

The  toxic  effects  observed  in  man  comprise  vomiting, 
purging  with  tenesmus,  a  feeble  and  a  slow  pulse  with 
cold  extremities,  and  great  prostration.  The  mucous 
membrane  of  the  stomach  and  of  the  intestine  has  been 
described  as  much  inflamed,  ulcerated,  and  even  '  gan- 
grenous '  in  cases  of  poisoning  by  the  drug. 

In  Sir  Everard  Home's  experiments,  the  injection  of 
colchicum  wine  into  the  jugular  vein  of  dogs  produced 
vomiting  and  bilious  diarrhoea.  The  breathing  was  re- 
markably slowed,  and  the  pulse  was  likewise  slowed  and 
depressed  in  strength,  but  later  it  became  very  rapid  and 
irregular.  After  death  the  mucous  membrane  was  con- 
gested and  inflamed  almost  throughout  the  intestinal 
tract.  These  results  would  point  to  a  decided  influence  of 
the  drug  in  three  directions — heart,  alimentary  canal,  and 
liver ;  and  the  same  influences  may  be  followed  out  in  the 
accounts  given  of  its  action  in  therapeutic  doses,  viz., 
depression  of  the  pulse,  purging,  rarely,  however,  vomiting, 
though  nausea  is  the  common  complaint  after  the  full 
dose. 

The  beneficial  effects  in  gout  have  been  variously  attributed 
to  the  same  influences ;  that,  however,  which  was  first 
noticed  and  described  was  the  action  on  the  kidney.  The 
marvellous  recoveries  from  dropsy  which  Storck  relates 
were  in  each  case  accompanied  with  the  passage  of  '  vast 
quantities  of  urine';  they  led  him  to  regard  the  drug  as 
essentially  a  diuretic. 

This  alleged  diuretic  action  has  not  been  recognised  in 
the  same  degree  by  most  observers ;  many  have  failed  to 
find  any  diuresis  whatever,  and  it  has  even  been  stated  by 
some  that  the  urinary  flow  was  diminished. 

This  want  of  unanimity,  this  positive  contradiction  in 


HISTORY  AND  PROPERTIES  OF  COLCHICUM        349 

the  results  of  separate  observers,  in  spite  of  a  careful  study 
of  the  effects  produced  on  the  urine,  and  the  absence  of 
any  marked  changes  in  the  quantity,  in  the  quality,  and 
in  the  constituents  of  the  secretion,  have  special  sig- 
nificance when  contrasted  with  the  energetic  action  of  the 
drug  upon  other  organs  and  functions. 

It  would  seem  diificult  to  ascribe  so  great  a  relief  as 
that  obtained  in  gout  to  the  operation  on  the  kidney 
of  subtle  and  hardly  recognisable  influences,  whilst  in 
other  directions  the  economy  is  being  searched  by  the 
violence  of  the  remedy.  Graves  was  probably  conscious 
of  this  inconsistency  when  he  sought  to  explain  the  bene- 
ficial action  of  colchicum  less  by  a  diminished  renal  excre- 
tion of  uric  acid  than  by  some  check  on  its  formation  in 
the  organism. 

CEsterlen  was  unable  to  find  any  alteration  in  the 
amount  of  urine  secreted,  or  in  its  percentage  of  urea  and 
of  uric  acid.  Baecker*  was  rather  inclined  to  admit  a 
diminution  of  the  relative  amounts  of  both  substances. 
Chelius,  on  the  other  hand,  has  reported  a  decided  increase 
in  the  output  of  uric  acid. 

Lecorchet  publishes  the  following  results  of  his  adminis- 
tration of  the  tincture  of  colchicum  (20  to  40  drops  in 
twenty-four  hours)  in  cases  of  gout  and  rheumatism : 
As  regards  (i)  the  amount  of  urine  secreted,  no  definite 
conclusions  could  be  drawn  from  the  varying  individual 
observations.  (2)  Reaction  :  In  all  cases  the  acidity  was 
markedly  reduced.  (3)  Urea :  No  definite  conclusions 
could  be  drawn.  (4)  Uric  Acid  :  In  the  rheumatic  cases 
the  quantity  was  irregularly  increased  or  diminished  ;  but 
in  both  cases  of  gout  submitted  to  the  treatment  the  uric 
acid  was  diminished,     (5)  Phosphoric  Acid:  No  definite 

*  '  Beitrage  zur  Heilkunde,'  Bd.  ii.,  1849. 

t  'Traite  Theorique  et  Pratique  de  la  Goutte,'  Paris,  1884. 


350        HISTORY  AND  PROPERTIES  OF  COLCHICUM 

conclusions  were  warranted  by  the  slight  and  varying 
modifications  noted.  (6)  Potassium,  Sodium,  Calcium  and 
Magnesiiim  :  In  another  series  of  observations  conducted 
in  three  cases  of  rheumatism  and  of  rheumatoid  arthritis, 
there  was  found  a  very  marked  increase  in  the  excretion  of 
potassium,  and  a  much  less  important  increase  in  the 
sodium  of  the  urine.  The  calcium  and  the  magnesium 
were  both  diminished. 

Of  the  various  functions  which  have  been  supposed  to 
be  influenced  by  colchicum,  that  of  the  kidney  is  obviously 
the  least  affected. 

Sir  A.  Garrod's*  conclusions  from  his  extensive  observa- 
tions on  the  influence  of  colchicum  on  the  urine  are  to 
this  effect :  (i)  '  There  is  no  evidence  to  show  that  colchicum 
produces  any  of  its  effects  upon  the  system  by  causing  the 
kidneys  to  eliminate  an  increased  amount  of  uric  acid ;  in 
gout,  when  the  drug  is  continued  for  any  lengthened  time, 
it  appears  to  exert  a  contrary  effect.'  (2)  '  We  cannot 
assert  that  colchicum  has  any  influence  upon  the  excretions 
of  urea,  or  of  the  other  solid  ingredients  of  the  urine.' 
(3)  '  Colchicum  does  not  act  as  a  diuretic  in  all  cases  ;  on 
the  contrary,  it  often  diminishes  the  quantity  of  urine, 
more  especially  when  it  produces  a  marked  effect  upon 
the  alimentary  canal.'  And  again  :  '  It  is  asserted  by  some 
that  colchicum  possesses  the  power  of  rendering  the  urine 
neutral,  or  even  alkaline ;  that  such  is  not  an  invariable 
effect,  my  own  observations  prove.' 

It  is  more  than  probable  that  individual  peculiarities 
partly  explain  the  difference  in  the  renal  effects  noted  by 
the  same  observers  at  different  times,  as  well  as  the  con- 
flicting statements  of  separate  authorities.  At  any  rate, 
the  evidence  in  support  is  not  sufficiently  conclusive  to 

*  Loc\  cit.,  p.  334. 


COLCHICUM  AS  A  SPECIFIC  35 1 

enable  us  to  regard  colchicum  as  strongly  modifying  the 
renal  function.  Again,  on  the  constitution  of  the  blood, 
we  are  not  in  a  position  to  trace  any  definite  action — if, 
indeed,  any  such  exist. 


MODE  OF  ACTION  OF  COLCHICUM  AS  A   SPECIFIC  IN 

GOUT. 

So  far,  the  evidence  as  to  the  mechanism  of  relief  is 
practically  negative. 

Three  directions  remain  in  which  we  might  seek  the 
desired  explanation  of  the  relief  given  in  gout  :  The 
cholagogue  and  purgative,  the  nerve-depressing,  and  the 
heart-depressing  property.  Most  probably  the  specific 
value  of  colchicum  resides  in  their  happy  combination. 
Each  separately  would  fail  to  relieve  ;  united  in  a  happy 
proportion,  as  they  are  in  colchicum,  they  succeed.  This 
view  is  suggestive ;  if  correct,  it  might  render  us  more 
hopeful  of  imitating  the  prescription  of  nature  by  artificial 
combinations,  whilst  opening  up  novel  aspects  of  the 
pathology  of  gout. 

Which  of  the  properties  in  question  is  most  to  be 
credited  with  the  result  it  is  impossible  to  say,  since  we 
are  not  even  certain  as  to  their  mechanism.  Whether  we 
turn  to  any  purely  sedative  or  to  any  purely  aperient  pro- 
perty, the  argument  employed  by  Sir  A.  Garrod  applies 
with  equal  force.  There  are  other  purgatives  and  other 
sedatives  more  potent  than  colchicum,  yet  they  will  not 
check  the  disease  as  colchicum  does. 

Again,  a  purely  nervous  influence  must  not  be  left  out  of 
consideration  ;  the  nervous  system  is  rapidly  brought  under 
the  action  of  any  soluble  principle  introduced  into  the 
blood,  and  must  experience  its  effects  for  good  or  for  evil. 
But  it  would  be  too  large  a  postulate  to  suppose  that 


352  COLCHICUM  AS  A  SPECIFIC 

colchicum  possessed  a  local  and  specific  action  upon  the 
hypothetical  medullary  centre  for  articulations  first  intro- 
duced to  our  notice  by  Dr.  Buzzard. 

Of  any  essentially  anodyne  virtue  in  colchicum  analogous 
to  that  of  opium,  we  know  nothing,  and  this  possibility 
may  be  almost  excluded.  We  are  compelled  to  look  to 
other  well-marked  properties  of  the  drug,  and  particularly 
to  its  cardiac  and  hepatic  effects. 

The  G astro-Intestinal  Action. — The  powerful  immediate 
action  exerted  on  the  gastro-intestinal  mucous  membrane 
has  already  been  described ;  it  forms,  as  it  were,  the 
central  and  most  tangible  feature  in  poisoning  by  col- 
chicum. The  purgative  action  is  not  the  earliest  in  the 
case  of  moderate  doses  ;  but  it  is  regarded  as  the  first 
indication  of  commencing  gastro-intestinal  irritation,  a 
result  of  the  drug  which  we  do  not  seek  in  gout.  A  feeling 
of  nausea  is  the  full  extent  of  the  physiological  effect 
which  we  desire  to  secure,  and  this  is  also  practically  the 
sign  that  the  full  therapeutic  value  has  been  obtained 
from  the  remedy. 

The  Cholagoo^ue  Action. — A  reasonable  theory  is  that 
which  has  attributed  the  relief  conferred  by  the  drug  to 
its  marked  cholagogue  property,  as  fulfilling  one  of  the 
most  important  indications  in  the  treatment  of  gout — the 
stimulation  of  the  secretion  of  bile.  Colchicum  has  been 
shown  by  Professor  Rutherford  to  be  one  of  our  most 
active  cholagogues.  Here,  again,  we  do  not  lose  sight  of 
the  interactions  which  probably  occur  between  mucous 
membrane,  nervous  system,  and  circulation.  A  great 
deal  may  be  brought  about  in  sympathy  with  the  local 
gastro-intestinal  stimulus,  the  hepatic  effect  itself  partly 
depending  upon  the  latter. 

The  Action  on  the  Circulation. — A  very  definite  vascular 
relief,  partly  realized  by  the  patients  themselves,  is  un- 


COLCHICUM  AS  A  SPECIFIC  353 

doubtedly  obtained.  Colchicum  not  only  slows  the  pulse 
but  depresses  its  strength — a  remarkable  contrast  with 
the  action  of  members  of  the  digitalis  group,  which  slow 
the  pulse,  but  increase  its  strength,  and  with  those  of  the 
atropine  group,  which  diminish  the  strength  whilst  in- 
creasing the  frequency. 

That  a  great  part  of  the  vascular  results  may  be  also 
merely  reflected  from  intestinal  irritation  is  rendered  likely 
by  the  fact  that  in  animals,  when  the  drug  is  injected 
directly  into  the  circulation,  the  heart  and  the  blood 
pressure  are  only  slightly  altered. 

Reasons  might  be  found  for  attributing  the  sedative 
action  on  the  sensorium  and  on  the  peripheral  nerves  to 
circulatory  changes.  If  the  latter  are  brought  about 
through  the  influence  of  a  vaso-motor  reflex,  then  the 
sedative  effect  would  be  secondary  to  the  local  action 
on  the  mucous  membrane.  For  this  surmise  we  have  the 
support  of  clinical  experience,  in  so  far  as  the  dose  that 
most  relieves  is  that  which  verges  on  the  production  of 
gastro-intestinal  irritation. 

Morphia,  which  relaxes  the  arterioles  and  diminishes 
the  tension  without  at  first  markedly  influencing  the  rate, 
is  in  this  respect  the  nearest  approach  to  colchicum,  from 
which  it  widely  differs  in  its  remaining  properties.  As 
regards  immediate  relief  to  the  painful  symptoms,  it  might 
probably  surpass  the  latter.  Unfortunately,  the  alleviation 
is  at  best  of  lim.ited  duration,  and,  for  reasons  elsewhere 
stated,  its  continued  administration  is  not  conducive  to 
the  patient's  ultimate  recovery.  All  practitioners  of  ex- 
perience are  agreed  as  to  the  comparative  failure  of 
opium,  and  leave  it  aside  in  the  systematic  treatment  of 
gout. 

The  mechanisms  for  the  reduction  of  vascular  tension 
also  differ.      Colchicum  probably  acts  by  counter-irritation 

23 


354  COLCHICUM  AS  A  SPECIFIC 

and  by  promoting  various  glandular  secretions  ;  morphia, 
by  reducing  the  perception  of  irritation,  whilst  rather 
checking  glandular  activity.  The  contrast  is  manifested 
in  the  later  physiological  effects  :  morphia  produces  con- 
stipation, and  checks  other  excretions ;  whilst  colchicum 
is  a  cholagogue,  and  perhaps  a  diuretic. 

The  question  thus  raised,  of  direct  importance  in  its 
relation  to  therapeutics,  is  worthy  of  consideration  also  in 
connection  with  the  pathology  of  the  vascular  reactions  of 
gout. 

The  cardio-vascular  effects  are  the  first  to  claim  our 
attention.  An  observation  of  the  local  phenomena  of 
acute  gouts  shows  us  a  violent  local  vascular  storm, 
turgid  veins,  paralyzed  arterioles,  the  mysterious  appear- 
ance of  oedema,  which  reminds  us  of  urticarial  rashes  or 
of  the  sting  of  insects.  The  pulse  is  tense  and  frequent, 
adding  by  its  tension  to  the  distressing  pressure  and  pain 
felt  in  the  inflamed  part. 

Cardiac  depressants  might  be  expected  to  mitigate  these 
evils,  and  colchicum,  which  abates  them  'like  magic,'  pro- 
bably acts  in  this  way. 

The  lowering  of  the  heart's  excitement,  and  of  the 
strength  of  beat,  is  at  once  felt  as  an  instalment  of  relief. 
The  lulling  of  the  pain  may  not  be  so  rapid  as  with 
morphia  or  an  anaesthetic,  but  it  is  more  lasting,  because, 
under  the  influence  of  colchicum,  derivation  takes  up  the 
work  begun  by  the  general  vascular  sedative  action,  and 
by  the  local  relaxation  of  the  blood-pressure. 

According  to  this  view,  the  alterative  and  the  hepatic 
properties  of  colchicum  would  actively  co-operate  with  its 
vascular  depressing  effects.  We  find  a  parallel  to  this 
supposed  mode  of  action  in  the  pacifying  influence 
exercised  on  the  restlessness  and   discomfort   of  infants 


CO  LC  HI  CUM  AS  A   SPECIFIC  355 

by  small  doses  of  calomel  or  of  grey  powder — an  influence 
so  marked  that  it  has  suggested  the  view  that  mercury 
might  act  as  a  hypnotic. 

Haig  connects  the  beneficial  effects  of  colchicum 
with  its  influence  on  the  excretion  of  uric  acid.  He 
recognises  in  colchicum  an  action  analogous  to  that 
of  some  of  the  metals,  which  induce  primarily  a  retention 
of  uric  acid  with  aggravation  of  gouty  pains ;  but  soon 
intestinal  irritation  is  set  up,  accompanied  with  a  fall  of 
urea  and  of  acidity,  and  uric  acid  is  discharged. 

The  power  of  colchicum  to  render  the  urine  neutral,  or 
even  alkaline,  was  not  borne  out  by  Garrod's  observa- 
tions. 

Sir  Dyce  Duckworth  is  of  opinion  that  '  a  large  part  of 
the  beneficial  effect  of  colchicum  in  gout  is  due  to  its 
decided  action  on  the  liver.  Powerful  cholagogue  action 
necessitates  active  hepatic  metabolism,  and  with  this  is 
secured  a  more  complete  disposal  of  uric  acid  and  other 
products,  which  are  believed  with  good  reason  to  be 
retained  in  the  liver  in  cases  of  gout.' 

In  conclusion,  though  we  have  insisted  upon  the  chola- 
gogue and  vascular  sedative  virtues  of  colchicum  as  the 
most  likely  agents  of  relief,  we  should  be  ill  warranted  in 
excluding  its  other  properties  in  forming  an  opinion  as 
to  the  mechanism  of  the  relief.  Our  impression  is  that 
the  merits  of  the  drug  may  reside  rather  in  the  finely- 
adjusted  combination  of  its  qualities  than  in  the  isolated 
strength  of  any  one  of  them.  Their  delicate  balance  may 
be  just  measured  for  the  work  needed,  and  may  constitute 
a  specific  aptness  which  no  other  distribution  of  power 
could  reproduce. 

If  colchicum  is  of  remedial  value  in  the  chronic  stage  of 
gout — and  on  this  point  we  have  a  consensus  of  opinion — 


356  COLCHICUM  AS  A  SPECIFIC 

if,  moreover,  it  possesses  a  preventive  value  when  ad- 
ministered during  the  interval — and  this  view  has  been 
largely  held — the  conclusion  is  almost  forced  upon  us  that 
the  mode  of  action  is  a  complex  one,  since  the  acute  stage 
where  the  relief  is  so  marked  entirely  differs  from  all 
other  stages  of  gout. 


CHAPTER  XL. 

COLCHICUM:  ITS  INDICATIONS  AND  CONTRA- 
INDICATIONS. 

THE  OBJECTIONS  URGED  AGAINST  THE  USE 
OF  COLCHICUM. 

Whilst  recognising  the  controlling  power  exercised  on 
gouty  inflammation  by  colchicum,  various  physicians  of 
eminence  have  been  impressed  with  the  injurious  effects  of 
a  continuance  of  the  drug,  or  of  its  administration  in 
large  doses.  This  adverse  opinion  has  been  largely  caused 
by  the  injudicious  use  made  by  the  patients  themselves  of 
patent  medicines,  such  as  the  Eau  Medicinale,  Wilson's 
Tincture,  Reynold's  Specific,  and  Laville's  Tincture. 
Scudamore  strongly  deprecated  the  use  of  the  Eau 
Medicinale,  though  he  approved  of  the  careful  administra- 
tion of  colchicum.  Todd,  however,  was  a  decided 
opponent  of  the  latter,  and  is  largely  responsible  for  the 
bad  name  which  has  been  attached  to  it. 

The  following  definite  objections  have  been  formulated  : 

1.  Even  in  the  absence  of  the  vomiting  and  of  the 
diarrhoea,  sometimes  of  a  severe  and  persisting  kind,  which 
indicate  gastro-intestinal  irritation,  the  drug  is  apt  to 
produce  a  degree  of  nausea,  depression,  and  languor, 
which  seriously  detract  from  the  value  of  the  relief  to  the 
local  symptoms,  and  lay  the  patient  open  to  their  almost 
immediate  return. 

2.  If  persevered  with,  it  lowers  the  vitality,  and  exposes 
the  patient  to  chronic  gout. 


358        OBJECTIONS  URGED  AGAINST  COLCHICUM 

3.  A  long  continuance  of  the  treatment  establishes  what 
has  been  termed  the  colchicum  habit,  viz.,  a  tolerance 
for  the  drug  and  a  worse  form  of  gout,  peculiarly  refractory 
to  this  as  well  as  to  other  remedies. 

With  regard  to  the  first  objection,  there  is  no  doubt  that 
some  subjects  are  unusually  susceptible  to  the  action  of  the 
remedy,  and  entertain  a  strong  aversion  to  it,  based  upon 
an  experience  of  its  depressing  effects.  In  many  of  these 
cases  the  drug  was  probably  less  to  blame  than  the  mode 
of  its  administration.     To  this  we  shall  presently  revert. 

The  second  objection,  viz.,  that  the  use  of  colchicum 
tends  to  change  acute  articular  into  torpid  visceral  gout, 
is  hard  to  disprove,  but  equally  difficult  to  prove.  Rendu 
finds  an  argument  against  it  in  the  number  of  those  who 
have  never  suffered  from  visceral  gout,  but  from  frequent 
acute  attacks,  in  spite  of  the  use  of  Laville's  tincture  or 
Lartigue's  pills. 

Considerable  weight  should  be  attached  to  the  testimony 
of  such  competent  authorities  as  Sir  Thomas  Watson, 
who  was  a  firm  believer  in  the  advantage  of  a  systematic 
course  of  colchicum,  and  of  Sir  A.  Garrod,  who  also 
advocates  its  employment. 

Lastly,  the  'colchicum  habit,'  according  to  Todd,  is  one 
easily  acquired,  whilst  the  drug  thus  abused  loses  its  effect 
for  good,  but  not  that  for  evil.  He  gives  the  famous 
instance  of  a  lady  of  rank — a  colchico-maniac — who  ulti- 
mately died  of  prostration  after  the  prolonged  use  of 
colchicum  in  100  minim  doses.  Todd  never  prescribed  it 
in  old  age  or  asthenia,  used  it  in  small  doses  only  (10  to  15 
minims  of  the  wine  or  i  grain  of  the  extract),  and  pre- 
ferred, even  in  the  case  of  strong  subjects,  to  forego  its 
aid,  if  possible,  believing  that,  whilst  shortening  the 
attacks,  it  also  shortened  the  interval  between  their 
recurrences. 


OBJECTIONS  URGED  AGAINST  COLCHICUM         359 

Few  physicians  will  be  found  to  recommend  the  con- 
tinuous and  protracted  use  of  so  potent  a  remedy. 
Nevertheless,  this  practice  has  been  occasionally  adopted 
without  detrimental  results.  Sir  Henry  Holland  once 
administered  it  for  two  years  consecutively  with  decided 
advantage.  The  patient,  however,  was  also  taking 
quinine.  With  this  drug,  more  than  with  most  others, 
individual  susceptibility  is  a  guide  to  medication. 

Lecorche  holds  that,  although  it  is  a  specific  rather  for 
the  acute  arthritic  or  visceral  gout  than  for  the  gouty 
habit,  it  may  be  used  continuously  as  an  anti-gouty 
remedy  ;  but  the  doses  should  be  smaller,  in  view  of  the 
possibility  of  membranous  enteritis  being  set  up. 

Galtier-Boissiere  (quoted  by  Lecorche,  loc.  cit.,  p.  603), 
taking  the  same  unfavourable  view  as  Todd,  has  recom- 
mended its  use  in  very  small  doses  and  on  alternate  days. 
Lecorche  condemns  so  pusillanimous  a  use  of  the  remedy, 
which  should  be  given  boldly,  though  not  long  continued. 
He  shares  in  the  belief  in  the  drug  expressed  by  Scuda- 
more.  Graves,  Watson,  Garrod,  Gairdner,  and  others ; 
and  he  holds  with  Graves  that  the  formation  of  uric  acid 
is  lessened  by  its  use,  which  also  restrains  within  cells 
that  undue  tendency  to  dissociation  which  he  regards 
as  characteristic  of  gout.  Of  its  superiority  over  sodium 
salicylate  he  entertains  no  doubt,  and  he  considers  it  to 
be  a  more  rapid,  as  well  as  a  safer,  remedy. 

THE  INDICATIONS  OF  COLCHICUM,  AND  THE  MODE  OF 

ITS  ADMINISTRATION,  CONTINUOUS  OR  INTER- 

MITTENT,  IN  LARGE  OR  IN  SMALL  DOSES. 

The  indications  for  a  vigorous  use  of  colchicum  are  much 
less  common  than  they  formerly  were.  The  violence  of 
the  acute  attack  is  less,  and  the  remedies  for  its  relief 
have  been  multiplied.     In  chronic  gout  we   trust    more 


36o  THE  CONTINUOUS  USE  OF  COLCHICUM 

than  ever  to  hygienic  and  dietetic  measures  and  to 
medicinal  agents,  such  as  the  iodides  or  the  saHcylates, 
which  act  more  slowly,  but  can  be  long  continued. 

Sir  A.  Garrod  regards  acute  gout  as  the  chief  indica- 
tion for  its  employment.  In  chronic  gout  it  should  be 
given  only  during  the  acute  exacerbation,  and  then  with 
great  care.  During  the  intervals  it  may  be  occasionally 
prescribed  '  as  a  cholagogue  in  lieu  of  the  preparations  of 
mercury.' 

The  continuous  use  of  the  drug  is  based  on  a  belief  in  its 
power  to  ward  off  attacks ;  but  this  mode  of  administra- 
tion defeats  its  own  ends.  The  opponents  of  colchicum 
have  done  service  to  the  cause  of  its  proper  and  well- 
regulated  use  by  showing  that  a  tolerance  of  the  drug  is 
above  all  to  be  avoided,  not  so  much  in  connection  with 
any  direct  toxic  danger,  as  with  the  eventual  loss  of  an 
advantage.  There  is,  however,  an  impression  that 
colchicum  may  be  sometimes  cumulative.  This  would, 
if  confirmed,  be  an  additional  argument  against  the 
continuous  administration.  This  practice  is  not  likely 
to  find  favour  with  the  physician,  but  will  probably 
still  be  carried  on  by  some  of  the  patients  who  manage 
their  own  case. 

The  intermittent  plan  is  that  best  suited  to  the  disease 
and  to  the  remedy.  On  the  grounds  of  a  distant  analogy 
with  digitalis,  much  may  be  said  for  the  intermittent  use 
of  the  drug  when  employed  (as  in  the  acute  attack)  as  a 
vascular  sedative.  In  digitalis  there  is  also  a  secondary 
or  later  action,  that  on  the  kidney,  which  it  may  not  in 
all  cases  be  necessary  to  elicit  or  to  keep  up.  Similarly 
with  colchicum,  it  may  be  wise  to  be  content  with  the 
relief  given  by  the  early  doses,  and  not  to  wear  out  the 
efficacy  of  the  drug  by  its  constant  administration. 

Full  doses,  followed  by  smaller  ones,  are  an  advantage. 


THE  MODE  OF  ADMINISTRATION  361 

This  method,  which  also  has  its  analogy  in  the  occasional 
practice  of  giving  large  single  doses  of  digitalis  in  heart 
disease,  provides  a  full  force  of  the  remedy  at  the  time 
when  it  is  most  needed,  and  when  any  depression  it  may 
produce  will  be  least  resented,  whilst  subsequent  doses 
may  be  kept  relatively  small,  and  free  from  much  risk  of 
disagreeing  with  the  patient.  Sir  A.  Garrod  recommends 
half  a  drachm  to  a  drachm  of  the  wine  at  starting,  and 
subsequent  doses  of  10  to  20  minims  twice  or  thrice  daily. 
He  believes  in  keeping  up  the  effect  in  a  mild  and  diminish- 
ing degree  for  several  days  after  the  inflammation  has 
subsided. 

Simultaneous  purgation  with  the  first  large  dose  by  means 
of  a  suitable  saline  is  an  approved  and  practical  plan  ;  it 
is  advocated  by  Sir  A.  Garrod.  The  immediate  effect  of 
the  dose  of  colchicum  is  partly  obtained,  but  its  after- 
effects are  avoided,  and  much  smaller  doses  will  then 
suffice  to  carry  on  the  action.  The  same  authority  con- 
demns the  use  of  colchicum,  in  the  larger  doses,  as  a 
purgative. 

The  dose  of  the  wine  of  colchicum  will  vary  with  the 
patient's  condition  and  age,  and  will  be  partly  determined 
by  the  pre-existing  state  of  the  bowels,  and  by  any  pre- 
liminary measures,  especially  purgative,  which  may  have 
been  taken.  When  administered  three  or  four  times  a 
day,  15  minims,  in  combination  with  salts  of  magnesia  or 
with  citrate  of  potash,  will  generally  be  amply  sufficient, 
and  the  dose  may  be  reduced  to  10  minims.  Alternative 
amounts  will  have  to  be  regulated  on  this  average  basis. 
The  guide  to  the  amount  to  be  administered  is  the  reaction 
of  the  patient  as  regards  the  pulse,  the  nervous  system, 
the  bowels,  and  the  skin  ;  it  has  already  been  stated  that 
the  diuretic  action  of  colchicum  is  subject  to  variations. 

The    nervous    indication    of    approaching    relief    is    the 


362  THE  MODE  OF  ADMINISTRATION 

diminution  of  pain  and  relative  comfort  sometimes 
obtained.  The  symptoms  of  intoxication  are  the  de- 
pression, the  faintness,  or  even  tremulousness,  which 
follow  excessive  doses,  and  are  accompanied  with  undue 
depression  of  the  pulse.  The  cutaneous  indication  of  relief 
is  gentle  perspiration,  which,  however,  is  not  always 
induced  ;  that  of  the  toxic  dose  is  a  clammy  cold  sweat. 

As  a  rule,  the  intestinal  effect  acts  as  a  premonitory 
indication  of  any  untoward  results  in  other  directions.  It 
is  noteworthy  that  colchicum  purgation  does  not  in  most 
cases  set  in  till  after  some  relief  to  the  pain  has  been 
obtained.  This,  of  course,  does  not  invalidate  the  view 
that  relief  from  the  pain  is  ultimately  an  outcome  of  the 
action  on  the  liver. 

It  is  impossible  to  determine  the  value  and  the  action 
of  any  vegetable  principles  possibly  contained  in  colchicum 
over  and  above  the  alkaloids ;  nevertheless,  various 
selective  powers  must  be  recognised  as  existing  in  plants, 
and,  in  this  instance,  we  are  quite  familiar  with  definite 
properties  of  the  drug,  and  especially  with  that  relating 
to  the  secretion  of  bile.  A  common-sense  view  would  be 
to  attribute  to  the  physiological  effect  on  the  liver  the 
apparently  proportionate  result  which  is  noticed  in  the 
relief  of  the  gouty  symptoms  ;  in  no  other  direction — 
except  that  of  gastro-intestinal  irritation  and  of  toxic 
nerve  and  heart  depression,  all  of  which  are  adverse  to 
the  cure  of  gout — do  we  find  any  action  so  definite  and 
considerable  as  the  cholagogue  action  insisted  on  by 
Professor  Rutherford,  who  finds  the  bile  not  only  more 
abundant,  but  more  watery  under  its  influence. 

I7i  prescribing  colchicum,  the  slight  differences  in  strength 
and  mode  of  action  between  its  preparations  should 
be  borne  in  mind.  The  tincture  from  the  seeds,  less 
commonly  used,  perhaps,  than  the  wine  of  the  corm,  is 


COLCHICUM  AND  VERATRINE  363 

about  one-third  more  aperient  than  the  latter.  Again,  in 
the  relative  activity  of  Battle's  recent  preparations,  the 
liquor  and  the  extract,  slight  differences  may  be  found. 
The  ammoniated  tincture  or  compound  tincture  of 
colchicum  is  prepared  from  the  seeds  with  sal  volatile  ; 
it  is  much  praised  by  some  physicians. 

As  to  the  alkaloid  colchicine,  it  may  sometimes  find 
application  as  a  hypodermic  remedy  in  minute  doses 
(5-Vth  to  ^th  of  a  grain)  where  special  reasons  exist  for 
this  form  of  medication.  Such  an  emergency  would, 
however,  be  extremely  rare. 

Sir  Dyce  Duckworth  has  also  tried  veratrine  externally, 
and  found  it  of  some  use  where  colchicine  afforded  none. 

In  administering  the  drug,  we  have  the  choice  of  two 
excellent  methods.  In  the  form  of  a  pill  the  extract  or 
the  acetous  extract  may  be  given  in  varying  doses,  and 
with  varying  frequency  according  to  the  dose.  Some 
practitioners  prefer  this  more  gradual  and  continuous 
action  of  the  drug  to  that  of  the  quicker-acting  draughts  ; 
and  the  dry  administration  of  the  remedy  is  often  con- 
venient and  grateful  to  the  patient. 

The  opposite  advantages  are  claimed  for  the  fluid 
administration  :  the  remedy  is  absorbed  more  quickly,  and 
probably  acts  with  greater  effect.  Most  valuable,  how- 
ever, is  the  facility  thus  afforded  of  combining  with  it 
useful  adjuncts.  Among  the  latter,  none,  perhaps,  is 
better  than  carbonate  of  magnesia,  with  or  without  a 
little  sodium  or  magnesium  sulphate,  disguised  by  spirits 
of  chloroform  and  peppermint-water,  or  some  other 
carminative. 

Veratria  has  rarely  been  given,  and  has  proved  unreliable 
and  unsatisfactory.  It  possesses  in  a  higher  degree  the 
faults  which  have  been  attributed  to  colchicum,  without 
possessing  its  virtues. 


CHAPTER  XLI. 

OTHER  MEDICINAL  AGENTS.— THE  ALKALINE 
TREATMENT. 

THE  TREATMENT  OF  GOUT  WITHOUT  COLCHICUM. 

In  spite  of  the  reputation  and  of  the  value  of  colchi- 
cum  as  a  specific,  we  are  becoming  more  and  more 
independent  of  its  use.  Is  this  a  phase  of  fashion,  or 
the  outcome  of  altered  conditions  ?  Quite  independently 
of  the  change  which  seems  to  have  come  over  the  type 
of  the  disease  as  manifested  by  the  present  generation,* 
telling  reasons  might  be  suggested  for  this  change  in 
the  tendency  of  practice. 

So  long  as  Sydenham's  doctrine  as  to  the  harmfulness 
of  purgatives  held  sway,  colchicum  was  the  more  indis- 
pensable, because  patients  were  largely  dependent  upon 
it  for  that  hepatic  relief  which  was  ostensibly  denied  them 
by  more  direct  means.  In  spite  of  theory,  they  ultimately 
secured  from  it  their  needful  purgation.  Hence,  also,  the 
popularity  of  various  quack  remedies  compounded  on  the 
unerring  lines  of  practical  clinical  results,  which  supplied 
it  without  stint. 

A  resumption  of  the  use  of  direct  hepatic  purges  at  once 
robbed  the  specific  of  some  of  its  employment.  The 
larger  doses  ceased  to  be  needed — nay,  had  to  be  avoided 
— their  effects  tending  to  discredit  unfairly  a  most  bene- 
ficial agent. 

'"■  Cf.  p.  20. 


THE  TREATMENT  OF  GOUT  WITHOUT  COLCHICUM   365 

To  this  circumstance  may  probably  be  traced  the  alleged 
uncertainty  of  its  action,  and  the  ever-recurring  doubts 
and  discussions  as  to  its  merits. 

A  ready  welcome  was  thus  assured  to  new  remedies 
well  backed  with  theoretical  credentials  from  modern 
chemistry.  The  alkaline  treatment  was  the  first  instal- 
ment of  this  promising  supply,  and  so  plausible  a  case 
could  be  made  out  in  its  favour,  that  it  long  held  an 
imperfectly  earned  position  in  spite  of  clinical  evidence. 
Indeed,  although  boldly  convicted  of  clinical  failure  by 
the  most  experienced  observers,  it  has  only  recently 
been  shown  by  Sir  W.  Roberts  to  be  based  upon  a 
chemical  misunderstanding. 

It  is  noteworthy  that,  although  it  was  instituted  long 
before  the  successes  of  the  alkaline  treatment  of  rheuma- 
tism, it  received  from  them  a  powerful  impulse.  The 
same  collateral  influence  was  to  repeat  itself  at  a  later 
date  in  connection  with  the  brilliant  achievements  of  the 
salicylic  group.  The  pain  of  rheumatic  arthritis  was 
benefited  in  so  striking  a  manner  that  the  yet  more 
painful  arthritis  of  gout  was  expected  to  yield  to  the  same 
influence.  Hitherto,  this  hope  has  not  been  fully  realized, 
but  its  partial  gratification  has  been  enough  not  only  to 
give  the  new  drug  a  place  in  the  therapeutics  of  gout,  but 
to  supply  with  a  powerful  argument  those  who  contend 
for  a  close  kinship  between  the  two  affections. 

To  what  extent  the  growing  favour  of  the  salicylates  is 
to  be  justified  in  the  future  remains  an  open  question. 
Dr.  Haig  holds  that  they  will  not  have  stood  a  fair  trial 
until  administered  in  the  same  large  doses  which  alone  are 
efficient  in  rheumatism — an  experiment  which  practical 
acquaintance  with  the  clinical  uncertainties  of  gout  has 
hitherto  discouraged. 

Moreover,  the   important    group  of  gouty  subjects,  in 


366    THE  TREATMENT  OF  GOUT  WITHOUT  COLCHICUM 

whom  the  renal  function  is  disordered  or  the  kidney- 
deranged,  could  not  be  submitted  to  the  treatment  in 
question,  even  moderate  doses  of  salicylate  being  some- 
times badly  borne  by  them.  Idiosyncrasies  in  this  respect 
cannot  be.  ascertained  beforehand,  and  cautious  prescrib- 
ing is  necessary. 

The  idea  of  subduing  the  inflammation  by  neutralizing 
excessive  acidity,  the  great  argument  in  favour  of  the  alka- 
line treatment,  has  been  revived  in  support  of  piperazine, 
lysidine,  and  other  alkaloids  of  considerable  neutralizing 
power,  which  do  not,  however,  modify  the  reaction  of  the 
urine  in  the  proportion  of  their  solvent  power  for  uric 
acid  in  the  test-tube.  Piperazine  has  recently  enjoyed  a 
limited  popularity  probably  not  destined  to  endure. 

The  symptomatic  treatment  of  the  pyrexia  and  pain  of 
gout  by  such  drugs  as  phenacetin  and  antifebrin  has  also 
swelled  the  list  of  the  modern  substitutes  for  the  treat- 
ment by  colchicum ;  and  the  treatment  by  the  benzoates 
has  been  chiefly  applied  to  chronic  gout. 

In  reviewing  these  methods  of  treatment,  which  have 
all  found  supporters,  we  are  led  to  trace  any  reputation 
they  may  have  gained  to  our  inability  even  with  colchicum 
to  cure  the  attack  immediately.  Granted  the  delay  in 
mending,  which  seems  to  be  inherent  to  the  acute  gouty 
process,  any  remedy  of  sufficient  authority  may  succeed 
in  satisfying  the  patient  and  the  physician  so  long  as  the 
preliminary  relief  has  been  secured  which  hygiene  of  the 
bowels  and  of  the  liver  and  diet  invariably  confer.  The 
question  as  to  the  relative  value  of  the  various  drugs  is  not 
solved  thereby.  We  may  gain  an  assurance  as  to  their 
innocuity,  but  we  obtain  imperfect  evidence  of  their 
efficacy  unless  they  should  be  tested  on  the  strict  lines  of 
experimentation.  In  the  case  of  colchicum  all  doubts 
have  long  been  set  at  rest  by  its  almost  unfailing  useful- 


THE  ALKALINE  TREATMENT  2>(>7 

ness  under  the  most  varied  conditions  of  administration, 
and  it  will  probably  remain  in  continued  possession  of  the 
high  place  it  has  long  occupied. 

Peiper*  and  Rumpff  have  shown  diminished  alkales- 
cence of  the  blood  to  be  of  common  occurrence  apart 
from  gout.  More  recently  an  acid  reaction  of  the  blood 
has  been  shown  to  occur  occasionally ;  this  points  to  the 
necessity  of  a  reconsideration  of  the  accepted  axiom  that 
blood  is  always  alkaline,  and  of  a  fresh  study  of  the  blood 
in  gout  from  this  special  point  of  view. 

THE  ALKALINE  TREATMENT. 

Ancient  pharmacology  has  to  be  scrutinized  rather 
closely  for  any  evidence  of  the  use  of  alkalies  and  alkaline 
earths  in  gout.  They  seem  to  have  played  a  subordinate 
part  until  the  middle  of  the  last  century.  The  ashes  of 
various  plants  prescribed  in  antiquity  were  probably  not 
credited  with  greater  virtues  than  a  thousand  and  one 
useless  remedies  then  in  vogue.  Nevertheless,  even  in 
those  early  days,  whether  as  the  result  of  observation  or 
merely  as  a  happy  guess,  reference  was  made  by  some 
authorities  to  the  benefici-al  action  of  earths  or  alkalies  in 
calculous  disease.  Pliny  recorded  a  belief  that  the  shells 
of  snails  would  expel  stone ;  Vitruvius  mentions  mineral 
waters  possessing  a  solvent  power  over  stone  in  the 
bladder ;  and  Galen  refers  to  the  power  of  splitting  up 
renal  calculi  attributed  to  the  concretions  within  the 
sponge.  A  curious  allusion  by  Paulus  ^gineta  to  certain 
authors  deprecating  the  unskilled  use  of  solvent  remedies, 
'  lest  they  should  lead  to  an  increase  in  the  size  of  the 
stone,'  reminds  us  of  similar  reservations   applicable  at 

*  Virchow's  Archiv,  1889. 

+  Centralblatt f.  Klin.  Med..,  1891. 


368  THE  ALKALINE  TREATMENT 

the   present   time   to   the    use    of   some    of  the   alkahne 
earths. 

The  caution  against  the  misuse  of  these  remedies  im- 
pHed  a  beHef  in  their  power.  Robert  Boyle  was,  accord- 
ing to  Lecorche,  whose  work  supphes  these  historical 
references,  one  of  the  earliest  representatives  of  the  idea 
of  the  chemical  solution  of  stone  in  the  bladder  by  internal 
remedies,  and  Boerhaave  explained  the  solvent  action  of 
alkalies  by  assuming  that  the  concretions  were  bound 
together  by  some  acid  which  an  alkali  would  remove. 

The  treatment  of  gout  in  Germany  by  the  administra- 
tion of  vegetable  ashes  in  Rhine  wine  was  a  revival  of  the 
'  decoction  of  ashes  '  of  the  ancients,  and  in  this  country 
Miss  Stephens'  remedy — containing  among  its  ingredients 
eggshells  and  soap — was  a  distant  imitation  of  the  remedy 
mentioned  by  Pliny.  Its  prolonged  use  was  thought  by 
Huxham  to  be  productive  of  harm. 

Sydenham,  who  recognised  the  diuretic  action  of  the 
lixiviating  salts  in  dropsy,  did  not  insist  on  their  value  in 
gout.  It  was  reserved  for  Cullen  to  dwell  upon  the 
practical  use  of  the  salts  of  lime,  of  the  absorbent  earths, 
and  of  soap  in  the  treatment  of  tophi.  Whytt's  '  Essay 
on  Lime-water,'  Edinburgh,  1752,  should  also  be  men- 
tioned. 

The  demonstration  of  the  presence  of  uric  acid  in  tophi 
by  Tennant  and  Pearson,  by  Wollaston,  and  by  Fourcroy 
at  the  close  of  the  eighteenth  century,  established  the 
reputation  of  the  alkaline  treatment  on  a  chemical  basis, 
and  since  then  it  has  received  increasing  recognition. 
Scudamore  and  Barthez  recommended  the  alkaline  and 
the  ammoniacal  carbonates  ;  Galtier  Boissiere  insisted  on 
the    special   value   of  the   potassium    salts ;    Ure*   called 

*  Lond.  Med.  Gazette,  November,  1844  ;  and  Med.  Times  and 
Gazette,  vol.  ii.,  1845,  p.  1415. 


THE  ALKALINE  TREATMENT  369 

attention  to  the  properties  of  the  salts  of  hthium  ;  and 
Buckle,  of  Baltimore,*  advocated  the  use  of  ammonium 
phosphate. 

In  some  quarters,  however,  the  new  method  met  with 
strenuous  opposition.  Trousseau  brought  against  it  the 
charge  of  converting  acute  sthenic  gout  into  the  chronic 
ailment,  and  of  setting  up  the  symptoms  of  the  alka- 
line cachexia,  viz.,  debility  with  ansemia,  and  tendency 
to  haemorrhage.  Owen  Rees  and  Golding  Bird  were  also 
numbered  among  its  opponents.  To  what  extent  these 
objections  may  have  been  well  founded  we  shall  presently 
consider.  They  did  not  suffice  to  stem  the  tide,  and  the 
chemical  arguments  put  forward  by  Garrod  gave  strong 
additional  support  to  this  method,  which  became,  as  it 
were,  the  classical  method  of  treatment,  although  in 
practice  its  application  was  by  no  means  always  rigidl}^ 
enforced,  and  of  late  years  has  been  varied  by  the  intro- 
duction of  entirely  new  medicinal  agents. 

Trousseau's  adverse  criticism  had  been  made  from  a 
purely  clinical  standpoint. 

After  a  long  interval  a  more  serious  objection  has  now 
been  raised  by  Sir  W.  Roberts  from  the  chemical  aspect 
of  the  question.  This  we  shall  proceed  to  set  forth  after 
stating  the  case  as  originally  made  out  in  favour  of  the 
method. 

THE  RATIONALE  OF  THE  ALKALINE  TREATMENT. 

The  Solvent  Action  of  Alkalies. — The  explanation  first 
suggested,  and  long  accepted  without  any  question,  was 
based  upon  elementary  chemical  considerations  in  con- 
nection with  Wollaston's  discovery  of  the  uratic  com- 
position of  tophi,  and  with  Garrod's  discovery  fifty  years 

*  C/.  Med.  Chir.  Review,  1847. 

24 


370     THE  RATIONALE  OF  THE  ALKALINE  TREATMENT 

later  of  the  presence  in  the  blood  in  gout  of  an  excess  of 
uric  acid.  The  alkaline  urates  being  much  more  soluble 
than  uric  acid  itself,  it  was  argued,  not  without  much 
apparent  reason,  that  the  administrations  of  alicalies  would 
cause  the  gouty  concretions  to  be  dissolved.  Although 
this  result  did  not  always  follow  with  the  completeness 
which  might  have  been  anticipated,  the  theoretical  correct- 
ness of  the  doctrine  remained  unchallenged,  and  it  was 
also  supported  by  the  following  considerations. 

The  neutralizing  action  of  alkalies  was  regarded  as  a  safe 
means  of  obviating  the  formation  of  uratic  concretions. 
Not  only  was  the  acidity  of  the  uric  acid  itself  disposed 
of,  but  the  excessive  acidity  which  was  a  well-ascertained 
feature  of  gout,  and  to  which  the  precipitation  of  uric  acid 
was  rightly  attributed,  was  also  to  be  suppressed  by  the 
alkaline  dose.  The  fact  that  the  intensely  acid  gouty 
urine  was  rendered  alkaline  was  held  to  be  a  demonstra- 
tion of  the  fulfilment  of  the  indication. 

Sir  W.  Roberts'  investigations  have  robbed  this  argument 
of  its  force.  The  reaction  of  the  urine  cannot  be  taken 
as  an  accurate  measure  of  the  relative  condition  of  the 
blood. 

The  Reaction  of  the  Blood* — The  question  as  to  the 
varying  alkalinity  of  the  blood  had  already  been  touched 
upon  by  Sir  A.  Garrod,  who  had  never  found  acidity,  but 
at  most  reduced  alkalinity,  in  the  blood  serum  in  gout. 
Sir  W.  Roberts  considers  that  the  reaction  may  at  most 
verge  on  neutrality.  A  diminished  alkalescence  of  the 
blood  is  not  special  to  gout  ;  it  has  been  described  in 
connection  with  the  various  forms  of  cachexia,  anaemia, 
leucocythaemia,  acute  rheumatism,  pneumonia,  diabetes 
and  pyrexia. 

Sir  W.  Roberts  points  out,  in  connection  with  the  same 

*  C/.p.  367. 


THE  RATIONALE  OF  THE  ALKALINE  TREATMENT    371 

subject,  that  it  is  difficult  to  disentangle  the  question  of 
the  possible  influence  of  the  complications  of  gout  on  the 
constitution  of  the  blood  from  that  of  the  direct  effect  of 
pure  gout ;  and,  in  order  to  avoid  any  confusion,  the  field 
of  study  would  have  to  be  restricted  very  carefully  to  the 
latter. 

There  are,  of  course,  other  aspects  to  the  administra- 
tion of  alkalies  in  gout  besides  that  of  an  attempted 
solution  of  the  deposits,  and  this  does  not  escape  Sir  W. 
Roberts'  attention.  Among  the  reasons  often  given  for 
their  administration  is  the  alleged  undue  prevalence  of 
acid  in  the  gouty  system ;  and  this,  as  stated  by  Sir  W. 
Roberts,  is  sometimes  regarded  as  amounting  to  a 
dyscrasia. 

The  Insolubility  of  the  Sodium  Biurate. — The  common 
belief  that  the  alkaline  carbonates  and  phosphates,  by 
increasing  the  alkalescence  of  the  blood,  add  to  its  solvent 
power  on  gouty  deposits,  and  delay  or  prevent  their 
formation,  is  negatived  by  Sir  W.  Roberts'  experimental 
evidence.  He  has  clearly  proved  that  alkalescence,  as 
such,  has  no  effect  whatever  on  the  solubility  of  sodium 
biurate  ;  and  he  has  shown,  moreover,  that  the  addition  of 
an  alkaline  carbonate  to  blood  serum  impregnated  with 
uric  acid  produces  no  appreciable  effect  on  the  process  of 
maturation,  and  on  the  advent  of  precipitation  of  the 
crystalline  biurate. 

In  this  respect  the  medicinal  treatment  of  gout  and 
that  of  gravel  are  shown  by  him  to  stand  on  an  abso- 
lutely different  footing.  '  The  urine  is  a  dead  excretion ' 
without  power  of  self-purification,  whilst  '  the  blood  is  a 
living  stream  with  high  powers  of  self-adjustment  to  a 
normal  standard.'  Again,  '  whilst  the  daily  average  of 
urine  discharged  amounts  to  some  50  oz.,  in  gout  we 
are  seeking  to  make  an  impression  on  a  much  larger  bulk 


372     THE  RATIONALE  OF  THE  ALKALINE  TREATMENT 

of  jfluid,  viz.,  on  the  totality  of  the  blood,  lymph,  and 
synovia,  a  quantity,  in  a  man  of  average  weight,  certainly 
not  less  than  20  lb.  A  practicable  dose  of  alkaline 
carbonate  which  will  enable  us  radically  to  alter  the 
urine '  will  produce  little  impression  on  the  larger  bulk  of 
fluid,  since  any  surplus  alkali  will  be  expelled  '  with  all 
speed  '  through  the  kidneys.  However  valuable,  there- 
fore, the  administration  of  alkalies  may  be  in  the  treatment 
of  gravel.  Sir  W.  Roberts  does  not  find  any  direct  object 
in  their  administration  for  gout. 

The  Clinical  Failure  of  the  Alkaline' Plan.  —  Sir  W. 
Roberts  supplements  this  chemical  criticism  by  con- 
clusions derived  from  clinical  observation ;  '  I  have  re- 
peatedly administered  the  bicarbonate  and  citrate  of  potash 
continuously  for  three  or  four  years,  and  in  sufficient 
doses  to  maintain  the  urine  persistently  alkaline,  yet  I 
have  seen  the  arthritic  attacks  recur  with  unabated  regu- 
larity.' This  experience  is  probably  that  of  many  prac- 
titioners, though  few  may  have  given  the  remedy  so 
patient  a  trial. 

The  alkaline  cachexia  dreaded  by  Trousseau  is  not 
mentioned  among  the  disappointments  incidental  to  this 
prolonged  alkalization  of  the  urine.  We  are  also  re- 
assured as  to  the  probability  of  so  untoward  a  result  by  a 
consideration  of  the  large  doses  of  alkali  which  can  be 
ingested  and  passed  through  the  kidney  without  any 
material  alteration  taking  place  in  the  reaction  of  the 
blood.* 

At  the  same  time,  where  potassium  salts  are  employed, 
we  should  not  lose  sight  of  the  toxic  properties  of  the 
metal,  which  are  dwelt  upon  under  another  heading. 
Chronic  gout  is  essentially  a  debilitating  disease,  and  in 
the  course  of  its  treatment,  which  cannot  altogether  re- 

*  Cy:  p.  380. 


THE  RATIONALE  OF  THE  ALKALINE  TREATMENT     373 

move  the  debility,  any  drug  bearing  an  evil  name  as  a 
depressant  is  sure  to  be  charged  with  some  of  the  blame. 
The  advisability  of  avoiding  the  use  of  depressing  thera- 
peutic agents  will  be  insisted  on  in  connection  with  the 
treatment  of  chronic  gout. 

The  alkalies  have  thus  failed  to  fully  justify  their 
original  reputation  for  efficiency.  They  fulfil  imperfectly 
the  two  chemical  indications  for  which  they  were  in- 
tended. The  solution  and  reabsorption  of  tophi  is  not  to 
be  brought  about  by  any  but  the  stronger  solutions  of 
potassium  salts,  and  a  powerful  alkalization  of  the  blood 
is  not  so  easily  to  be  obtained.  From  their  failure  in 
these  directions,  it  by  no  means  follows  that  the  alkaline 
method  is  useless,  or  that  the  individual  alkaline  remedies 
are  inert  in  gout,  unless  pushed  to  their  toxic  doses  ;  but 
the  farther  we  step  away  from  mere  chemical  reactions 
and  formulae,  the  more  difficult  it  becomes  to  provide 
scientific  evidence  of  their  value.  Nevertheless,  long 
accumulated  clinical  evidence,  and  the  constantly  recur- 
ring testimony  of  patients  under  treatment,  must  carry 
weight  in  considering  the  practical  question. 

Whether,  as  has  sometimes  been  alleged,  the  kidneys 
may  be  assisted  by  alkalies  in  the  act  of  separating  uric 
acid  from  the  blood  is  matter  for  pure  speculation. 
There  is  no  obvious  improbability  in  this,  and  much  to 
suggest  it  as  likely ;  but  experimental  evidence  is  still 
wanting,  and  the  present  data  are  of  a  somewhat  contra- 
dictory nature. 

Physiology  provides  us,  however,  with  suggestions  of  a 
more  definite  kind  in  connection  with  metabolism,  and 
particularly  with  hepatic  metabolism.  Two  theories  have 
been  entertained  in  explanation  of  the  beneficial  results 
undoubtedly  obtained  by  the  administration  of  some  of 
the  alkalies  or  alkaline  earths,  and  to  these  we  may  refer 


374     THE  RATIONALE  OF  THE  ALKALINE  TREATMENT 

under  the  heading  of  the  alterative  and  oxidation  theory, 
and  the  theory  of  hepatic  and  glandular  stimulation. 

The  alterative  action  of  alkalies  and  of  their  salts  is 
hitherto  imperfectly  understood.  It  probably  depends 
largely  upon  their  solubility,  which  brings  them  into  inti- 
mate contact  with  all  the  constituents  of  the  body ;  any 
affinities  which  they  may  possess  are  in  this  way  brought 
extensively  into  play.  The  powerful  attraction  of  the 
alkaline  metals  for  oxygen,  and  of  their  hydrates  for 
water,  sufficiently  explains  their  destructive  caustic  action 
on  tissues.  Their  salts  are  destitute  of  any  strong  action 
of  this  kind.  A  distinction  must  be  made,  however,  be- 
tween the  alkaline  salts  of  the  mineral  acids  and  those  of 
the  organic  acids,  and  especially  of  carbonic  acid.  The 
relatively  feeble  stability  of  the  combinations  belonging  to 
the  latter  group  brings  them  perceptibly  nearer  to  the 
hydrates  in  their  physiological  action.  The  alkaline 
carbonates  are  more  likely  to  be  split  up  and  to  yield  a 
supply  of  the  base  available  for  combination  with  the 
tissue  elements.  For  the  latter  the  alkalies  and  especially 
potash,  possess  a  marked  affinity,  which  is  probably 
not  limited  to  the  formation  of  alkali  albuminate  with 
their  albumen. 

In  these  various  ways  the  alkaline  salts  bring  about  an 
appreciable  increase  in  the  rate  or  in  the  activity  of  meta- 
bolism. If  they  do  not  themselves  play  the  part  of 
oxidizers,  they  promote  in  the  tissues  changes  which  are 
bound  up  with  oxidation.  An  indirect  proof  of  the 
accelerated  metabolism  is  afforded  by  the  increased 
excretion  by  the  kidney  of  urea  and  of  sulphuric  acid 
noted  by  Parkes  after  small  doses  of  liquor  potassse,  and 
by  the  fact  that  *  an  increased  consumption  of  sodium 
chloride  not  only  increases  the  quantity  of  it  and  of  urea 
in  the  urine,  but  also  increases  the  excretion  of  potash 


THE  RATIONALE  OF  THE  ALKALINE  TREATMENT    375 

salts ;  whilst,  on  the  other  hand,  potash  salts  also  increase 
the  excretion  of  sodium.'* 

It  is  superfluous  to  point  out  that  the  torpid  metabolism 
of  gout  is  a  special  indication  for  the  employment  of 
agents  of  this  kind. 

The  stimulating  effect  on  the  mucous  membranes  and  their 
glands  is  another  important  recommendation.  Much  of 
the  benefit  is  doubtless  to  be  ascribed  to  the  solvent  action 
for  mucus,  and  in  the  intestinal  canal  to  the  local  neutraliza- 
tion of  any  excess  of  acidity.  In  addition,  they  increase 
the  amount  of  gastric  juice  and  the  flow  of  bile.  Clinical 
evidence  of  their  value  in  dyspepsia  has  been  abundantly 
corroborated  by  physiological  experiments. 

Their  diuretic  action,  combined  with  their  antacid  pro- 
perty, is  also  of  direct  service  in  promoting  elimination  of 
the  soluble  excreta. 

This  brief  review  of  some  of  the  physiological  activities 
of  the  alkaline  salts  will  suffice  to  show  that  their  useful- 
ness in  gout  cannot  be  correctly  measured  by  their  co- 
eflicient  of  solvent  power  for  uratic  deposits,  nor  even  by 
the  increase  of  alkalinity  which  they  may  confer  on  the 
blood.  We  shall  now  proceed  to  note  the  individual 
peculiarities  of  each  member  of  the  group. 

*  Lauder  Brunton,  '  A  Text-book  of  Pharmacology,  Therapeutics, 
and  Materia  Medica,'  p.  527.     London  :  Macmillan  and  Co.,  1885. 


CHAPTER  XLII. 

THE  ALKALINE   SALTS   AND  THEIR  USES   IN 

GOUT. 

THE  SALTS  OF  POTASSIUM. 

Lecorche  attributes  to  J.  Guerin  (1746)  the  earliest  pub- 
lished observations  of  the  efficacy  of  potassium  salts  in 
uric  acid  gravel,  and  to  Mascagni  (1804)  a  confirmation 
of  the  same  favourable  report ;  whilst  Rendu  claims  for 
Galtier  -  Boissiere  the  honour  of  that  discovery.  The 
solvent  power  of  potassium  salts  has  been  amply  proved 
since  then,  and  they  have  been  freely  used  in  this  country, 
and  subsequently  on  the  Continent.  They  had,  however, 
been  administered  for  gout  by  the  ancients  in  the  vegetable 
ashes  then  prescribed, 

Garrod's  experimental  demonstration  of  the  rapid  solu- 
tion of  uratic  deposits  in  cartilages  immersed  in  a  solution 
of  potassium  carbonate,  whilst  sodium  carbonate  solutions 
exerted  hardly  any  solvent  action,  have  been  confirmed 
by  Sir  W.  Roberts,  who  has  shown  that,  in  their  marked 
influence  in  delaying  the  maturation  of  the  sodium  biurate, 
the  potassium  salts  occupy,  in  the  alkaline  group,  a  unique 
position.  They  are,  from  the  point  of  view  of  the  uratic 
precipitations  in  gout,  the  remedies  par  excellence.  Moreover, 
their  alkalizing  power  exceeds  that  of  the  other  alkahes, 
with  the  exception  of  lithium.  Their  diuretic  action  is 
also  greater  than  that  of  any  of  the  others. 

The  physiological  affinities  of  potassium  are  also  quite 
special.     Potassium,  in  combination  with  phosphoric  acid. 


\ 


THE  SALTS  OF  POTASSIUM  377 

is  a  constituent  of  all  growing  cells,  and  is  largely  con- 
tained in  the  red  blood-corpuscles — which  hold  it  firmly, 
in  spite  of  its  high  solubility  and  of  the  facilities  for  its 
escape  into  the  plasma — and  in  the  substance  of  muscles. 
In  connection  with  this  strong  attraction  exerted  on  them 
by  the  solid  elements  of  the  tissues,  the  salts  of  potassium 
are  credited  with  a  stronger  metabolic  influence  than  those 
of  sodium  and  of  lithium.  This  may  also  be  correlated 
with  the  toxic  action  special  to  them.  According  to 
Rendu,  6  to  8  grammes  will  act  as  a  poison,  whereas 
much  larger  doses  of  sodium  are  harmless. 

The  toxicity  of  the  salts  of  potassium  has  been  studied 
by  Feltz  and  Ritter,  and  subsequently  by  Bouchard,*  in 
connection  with  the  toxicity  of  urine,  and  with  the  patho- 
genesis of  uraemia. 

Bouchard  states  that  the  quantity  of  sodium  chloride 
which  would  kill  i  kilogramme  of  animal  is  5'i7  grammes, 
and  this  is  the  most  toxic  of  the  salts  of  sodium.  Thus, 
the  total  amount  secreted  in  twenty-four  hours  would  only 
kill  2  kilogrammes,  whilst  the  total  urine  itself  would  kill 
30  kilogrammes.  The  most  toxic  among  the  salts  of 
potassium — viz.,  the  chloride — kills  in  the  proportion  of 
18  centigrammes  per  kilogramme  of  animal ;  the  phosphate 
is  not  toxic  under  a  proportion  of  26  centigrammes,  and 
the  phenylsulphate  is  still  less  toxic.  In  spite  of  the  high 
toxicity  of  the  salts  of  potassium,  Bouchard  cannot  agree 
with  the  conclusions  formed  by  Feltz  and  Ritter,  to  the 
effect  that  the  toxicity  of  urine  is  due  to  its  mineral  con- 
stituents. In  order  to  kill  by  potash,  a  quantity  is  some- 
times needed  double  that  which  is  contained  in  the  quantity 
of  urine  (40  to  60  cubic  centimetres,  or  on  the  average  45 
cubic  centimetres)  which  usually  causes  death.  Moreover, 
whilst  death  from  potash  is  preceded  by  convulsions,  this 
is  not  the  case  with  poisoning  by  normal  urine  secreted  in 
*  Cy.  'Auto-intoxication  in  Disease,'  p.  120  et  seq. 


37^  THE  SALTS  OF  POTASSIUM 

the  middle  of  the  day  ;  neither  is  arrest  of  the  heart  noticed 
in  this  case.  From  the  fact  that  healthy  decolourized 
urine  kills  without  convulsions,  Bouchard  supposes  that 
an  antagonism  may  exist  between  potash  and  the  '  con- 
vulsive urinary  principles.'*  On  the  other  hand,  some 
pathological  urines,  especially  the  febrile,  retain  their  con- 
vulsive power  in  spite  of  decolourization  ;  this,  Bouchard 
suggests,  may  be  due  to  an  excess  of  potash  derived  from 
an  increased  cellular  destruction. 

Moreover,  Bouchard's  experiments  show  that  the  char- 
coal filter,  which  retains  only  one-sixteenth  of  the  total 
potash,  removes  one-third  of  the  toxicity  of  urine  (colouring 
matter,  extractives,  and  alkaloids),  including  a  convulsive, 
a  pupil-contracting,  and  a  temperature-lowering  principle. 

At  the  most,  Bouchard  estimates  the  '  mineral '  toxicity 
of  urine  at  57  per  cent,  of  the  total  urinary  toxicity,  and 
the  'potassium '  toxicity  only  at  47  per  cent,  of  the  same. 

The  following  table  of  toxicity,  drawn  up  from  experi- 
ments by  Bouchard  and  Tapret,  but  which  unfortunately 
does  not  include  lithium,  illustrates  the  strong  contrast 
between  the  salts  of  potassium  and  those  of  sodium.  The 
weights  in  grammes  represent  the  quantity  of  each  sub- 
stance  which   is    necessary    to    kill   one    kilogramme    of 

animal : 

Index  of    ^ 

c-  1  ,■         Grammes. 

bolution. 

Chloride  of  potassium  -  -  -^\q  o"i8o 

Sulphate  of  potassium  -  -  o§g-  o'iSi 

Phosphate  of  potassium  -  -  000  o"263 

Chloride  of  sodium  -  -  ^-o  5'i7 

Sulphate  of  sodium  -  -  ]^o  9'oo 

Phosphate  of  sodium  -  -  ^^^  6"oo 

Chloride  of  magnesium  -  -  200  o'463 

Sulphate  of  magnesium  -  -  000  o'542 

Chloride  of  calcium  -  -  300  roii 

*  These    Bouchard   has   shown   to   be   insoluble   in  alcohol,  their 
antagonists,  the  narcotic  urinary  principles,  being  soluble. 


THE  SALTS  OF  POTASSIUM  379 

These  observations  are  worthy  of  consideration  in 
connection  with  gout,  in  which  it  is  known  that  the 
elimination  of  the  urinary  constituents  is  not  at  all  times 
performed  with  completeness. 

Death  in  potassium-poisoning  is  due  to  arrest  of  the 
heart's  action,  and  is  preceded  by  convulsions.  The  action 
is  supposed  to  be  a  direct  one  on  the  tissues,  and  parti- 
cularly on  the  nervous,  muscular,  and  cardiac  tissues. 
In  the  language  of  therapeutics,  potassium  salts  are  de- 
pressants, and  this  is  an  important,  though  it  appears  to 
be  the  only,  reservation  to  be  made  in  connection  with  its 
use.  As  a  diuretic  and  solvent,  as  an  alkalizer,  as  a 
diaphoretic,  as  an  hsematinic,  and  in  the  accelerating 
influence  which  it  exerts  on  metabolism,  it  is  a  powerful 
and  beneficial  agent. 

The  usual  form  for  its  administration  is  the  bicarbonate, 
of  which  small  doses  are  harmless,  and  larger  doses,  such 
as  a  drachm,  are  often  in  other  diseases,  and  particularly 
rheumatism,  continued  for  many  days  without  any  evil 
effect. 

THE  SALTS  OF  SODIUM. 

The  peculiarities  of  the  sodic  salts  are  the  converse. 
They  are  free  from  the  reproach  of  toxicity  in  the 
ordinary  range  of  their  administration,  but  they  incur 
that  of  inefficiency  as  solvents  of  uric  acid — nay,  the 
graver  reproach  of  promoting  its  precipitation — and  to 
this  we  shall  presently  revert. 

Beneke,*  in  contrasting  the  potassium  and  sodium 
compounds,  refers  to  the  diverging  mode  of  chemical 
reactions  observed  by  Kolbe,t  who  obtained  salicylate 
of  sodium  from  sodium  phenate  and  carbon  dioxide, 
whilst  potassium  phenate  yields  the  paraoxybenzoate — 

'^  Joiirn.fiir  Prakt.  Chemie,  1874.  t  Quoted  by  Lecorche. 


38o  THE  SALTS  OF  SODIUM 

and  he  regards  the  physiological  actions  as  different  also, 
sodium  salts  taking  effect  chiefly  on  the  fluids  and  deter- 
mining a  temporary  alkalinity,  whilst  the  potassium  salts 
tend  to  combine  with  the  tissues. 

The  physiological  affinities  of  sodium  are  also  the  con- 
verse of  those  of  potassium.  It  does  not  enter  so  largely 
into  the  constitution  of  the  solid  elements,  but  is  tenaciously 
held  by  the  serum  and  other  fluids.  A  minimum  supply 
of  sodium  chlorides  is  well  known  to  be  one  of  the  most 
urgent  necessities  of  the  organism,  whilst  an  excess  of 
this  commodity  is  well  borne,  and  does  not  raise  the 
sodic  standard  of  the  serum,  but  passes  out  harmlessly 
through  the  kidneys. 

These  remarkable  facts  dispose  in  great  measure  of 
the  objection  urged  by  Trousseau  and  others  against  the 
free  use  of  this  alkali.  Rendu  refers  to  the  results  of 
Charcot  and  Bouchard,  who  administered  as  much  as 
30  grammes  of  the  bicarbonate  daily  for  months  with- 
out producing  any  anaemia  ;  and  he  does  not  conceive 
that  the  alkaline  cachexia  can  be  set  up  by  anything  short 
of  a  long  continuance  of  enormous  doses  of  the  salt. 

On  the  other  hand,  the  persistence,  for  prolonged 
periods,  of  an  alkaline  reaction  after  the  temporary  use 
of  moderate  doses  of  the  alkaline  salts  is  not  so  easily 
explained  in  the  case  of  the  sodium  bicarbonate  as  in 
that  of  the  salt  of  potassium,  and  we  see  in  it  an  indica- 
tion of  a  definite  alterative  action  special  to  sodium. 

The  insolubility  of  sodium  urate  has  always  been  urged 
against  the  medicinal  use  of  the  sodic  salts  ;  and  in  con- 
nection with  the  every-day  treatment  of  gout,  and  with 
its  treatment  by  mineral  waters,  this  objection  has  taken 
a  practical  form,  and  has  given  rise  to  discussions  which 
will  be  considered  in  another  section.  It  will  be  readily 
perceived,    however,  that    too    much    might  be  made    of 


THE  SALTS  OF  SODIUM  381 

the  allegation  in  question.  The  ordinary  gouty  person 
is  never  sodium-starved.  There  is  always  present  in  his 
economy  a  considerable  excess  of  sodium  over  and  above 
the  indispensable  minimum,  an  excess  much  larger  than 
the  quantity  which  might  be  claimed  for  the  disposal  of 
the  daily  accumulation  of  uric  acid  in  the  shape  of 
biurate.  It  does  not  appear  that  any  additional  excess 
could  affect  the  result.  This  is  a  uric  acid  question,  not 
a  sodium  question.  If  it  could  be  shown  that  undue  rich- 
ness of  the  blood  in  sodium  led  to  an  increased  formation 
of  uric  acid,  we  should  indeed  be  careful  in  its  adminis- 
tration. On  this  point  experimental  evidence  would  be 
welcome  ;  it  must  be  owned  that  hitherto  clinical  evidence 
inclines  in  the  opposite  direction.  Lecorche  does  not 
hesitate  to  ascribe  to  sodic  salts  a  power  of  diminishing 
the  formation  as  well  as  that  of  promoting  the  excretion 
of  uric  acid. 

The  action  on  the  mucous  membrane  mentioned  as  one 
of  the  properties  of  alkalies  is  conspicuously  possessed 
by  the  sodium  bicarbonate,  which  is  almost  universally 
prescribed  in  preference  to  any  other  salts  for  the  relief 
of  dyspepsia.  This  success  is  partly  due  to  its  direct 
stimulating  effect  on  the  gastric  secretion,  but  there  is 
another  property  which  it  does  not  share  with  any  other 
metal,  and  which  largely  explains  its  many-sided  use- 
fulness. 

As  a  cholagogue  and  hepatic  stimulant  sodium  possesses 
an  undisputed  advantage  over  potassium  and  other  mem- 
bers of  the  group.  It  is  an  essential  constituent  of  bile, 
as  the  combining  base  for  glycocholic  and  taurocholic 
acid,  and  the  ingestion  of  its  salts  has  been  proved  by 
repeated  experiments  to  promote  the  flow  of  bile.  A 
dose  of  Vichy  water  leads  to  an  immediate  discharge  of 
bile  in  dogs  presenting  a  biliary  fistula.     To  this  chola- 


382  THE  SALTS  OF  SODIUM 

gogue  action  much  of  the  therapeutic  value  of  sodium 
bicarbonate  is  doubtless  to  be  ascribed.  By  stimulating 
the  function  of  the  liver,  it  must  efficiently  assist  in 
restoring  the  mucous  membranes  to  a  healthy  condition. 
Catarrhs  in  general,  not  only  those  of  the  stomach,  intes- 
tines, and  biliary  ducts,  but  also  the  genito-urinary  and 
bronchial  catarrhs,  are  much  benefited  by  its  administration 
in  aerated  solutions. 

These  advantages  make  out  a  strong  case  in  favour  of 
the  sodium  treatment.  Lecorche  gives  it  his  decided 
support.  Having  observed  a  persistence  of  the  alkaline 
effect  of  sodium  salts  for  a  considerable  time  after  a  few 
days'  administration,  and  bearing  in  mind  the  cardiac 
depression,  the  occasional  diarrhoea,  and  other  risks 
attaching  to  medication  by  salts  of  potash,  he  strongly 
prefers  the  sodium  compounds  to  all  others,  including 
those  of  lithium  ;  and  he  regards  them  as  not  markedly 
inferior  in  the  three  actions  which  he  attributes  to 
alkalies,  viz.,  (i)  that  of  checking  undue  dissociation  of 
organic  cells ;  (2)  that  of  dissolving  deposits  of  a  uratic 
nature ;  (3)  that  of  opposing  an  increased  alkalinity  of 
the  blood  to  the  tendency  to  precipitation  of  the  acid 
biurate.  Thereby  the  out-put  of  uric  acid  is  much 
increased. 

At  the  same  time,  the  most  sanguine  advocate  should 
not  overlook  the  question  of  individual  peculiarities  in  the 
patient.  Some  persons  are  much  more  readily  alkalized, 
and  others  stand  alkalizing  very  badly.  Judgment  should 
be  exercised  in  discriminating  cases. 

Again,  any  remedy  may  be  administered  too  freely,  too 
continuously,  or  too  long.  The  question  of  doses  is  an 
important  but  difficult  one.  Effects  very  dissimilar,  and 
even  contrary,  may  sometimes  be  obtained  from  the  same 
agents,  according  as  they  are  used  in  minute  or  in  excessive 


THE  SALTS  OF  SODIUM  383 

amounts.  A  comparative  study  of  this  kind  is  needed  in 
the  case  of  the  sodium  salts  in  connection  with  the  treat- 
ment of  gout,  by  reason  of  the  wide  range  of  their  non- 
toxic dose.  For  the  present,  we  should  be  content  with 
the  decided  benefit  accruing  from  their  administration  in 
moderate  quantities  so  long  as  we  lack  evidence  of  their 
mode  of  action  when  given  on  a  larger  scale. 

Their  intermittent  euiployment  is  also  to  be  preferred  to 
their  continuous  administration  through  prolonged  periods. 
The  indications  for  an  interruption  of  the  treatment  will 
be  supplied  by  the  peculiarities  of  each  case.  They 
probably  form  no  exception  to  the  rule  that  the  activity 
of  drugs  is  lessened  by  the  establishment  of  '  tolerance,' 
and  that  the  advantage  which  may  thus  be  lost  is  to  be 
measured  by  the  degree  of  their  initial  efficacy. 

In  conclusion,  the  strongest  proof  which  we  can  adduce 
of  the  value  of  the  sodium  salts  in  gout  is  the  fact  that  to 
the  present  day  they  are  largely  prescribed,  especially  on 
the  Continent,  and  largely  taken  also  in  the  shape  of 
mineral  waters,  in  spite  of  the  experimental  evidence  which 
has  denied  to  them  any  important  direct  solvent  power 
for  uratic  deposits,  and  placed  them  under  a  suspicion  of 
increasing  their  precipitation.  They  have,  moreover,  en- 
joyed a  much  earlier  popularity  in  connection  with  gout 
than  those  of  potassium,  and  especially  of  lithium,  the 
last-named  having  been  introduced  at  a  comparatively 
recent  date ;  for  sodium  is  stated  to  have  been  the  basis 
of  Sydenham's  'lixiviating  salts,'  and  of  the  soaps  recom- 
mended by  Van  Swieten,  Cullen,  Boerhaave,  and  many 
others. 

THE  SALTS  OF  LITHIUM. 

The  question  as  to  the  value  of  lithium  in  gout  has 
given  rise  to  considerable  discussion,  and  is  still  sub  jiidice. 


384  THE  SALTS  OF  LITHIUM 

Discovered  by  Arfewdson  in  1817,  in  petalite,  it  has  since 
then  been  obtained  from  lepidoHte,  and  from  numerous 
mineral  springs,  including  those  of  Carlsbad,  Aix-la- 
Chapelle,  Marienbad,  Kissingen,  Ems,  Teplitz,  Bilin, 
Kreuznach,  Vichy,  Baden,  and  many  others ;  it  has, 
moreover,  as  stated  by  Garrod,  been  recognised  by  means 
of  the  spectroscope  as  one  of  the  most  widely  diffused 
metals  throughout  the  vegetable  and  the  animal  kingdom, 
and  '  must  be  regarded,  not  as  a  drug  foreign  to  the 
econom}',  but  as  a  normal  constituent  of  the  body.' 

The  soluhility  of  uric  acid  in  solutions  of  carbonate  of 
lithium  was  first  turned  to  a  therapeutical  purpose  by 
A.  Ure,  who  proposed  to  inject  the  carbonate  into  the 
bladder  as  a  solvent  for  stone,  and  described,  in  the 
Pharmaceutical  Journal  for  1843,  his  experimental  trial  on 
a  stone  immersed  into  a  solution  kept  at  the  temperature 
of  the  body.  Sir  A.  Garrod  was,  however,  the  first  to 
employ  the  remedy  systematically  for  the  treatment  of 
gravel  and  of  gout.  Adding  a  further  proof  of  the  extra- 
ordinary solubility  of  the  lithium  urate  to  that  given  by 
Lipowitz,  who  found  that  uric  acid,  when  boiled  with 
pulverized  lepidolite,  displaces  the  silicic  acid  of  the 
mineral  in  virtue  of  its  more  powerful  affinity  for  lithium,  he 
showed  that,  'when  carbonate  of  lithia  in  excess  is  boiled 
with  water,  the  addition  of  uric  acid  causes  it  to  dissolve, 
proving  that  the  urate  of  the  base  is  more  soluble  than 
the  carbonate,'  and  identified  the  long  crystalhne  needles 
subsequently  obtained  as  those  of  the  biurate  of  lithium. 

By  placing  pieces  of  cartilage  infiltrated  with  uratic 
deposit  into  saline  solutions  of  the  three  metals,  he  found 
that  after  forty-eight  hours  the  lithia  had  completely  dis- 
solved the  incrustations,  potash  only  part  of  them,  and 
soda  not  any. 

These  and  similar  experiments  placed  beyond  doubt  the 


THE  SALTS  OF  LITHIUM  385 

solvent  power  of  the  metal  for  uric  acid  even  when  em- 
bedded in  the  tissues,  and  led  him,  in  1858,  to  administer 
the  carbonate  of  lithium  internally. 

The  chemical  properties  of  lithium  are  those  of  an  alkaline 
metal.  In  specific  gravity  and  in  atomic  weight,  it  is  the 
lightest  of  metals.  Under  equal  weights,  its  salts  there- 
fore represent  a  higher  neutralizing  power  than  those  of 
sodium  or  potassium.  The  carbonate  is  less  soluble  (i  in 
150  of  water)  than  the  sodium  and  also  than  the  potassium 
carbonate,  but  an  excess  of  carbonic  acid  improves  its 
solubility.  The  citrate  is  much  more  soluble  (i  in  2i  of 
water). 

Its  action  in  the  economy  has  been  regarded  as  that  of  an 
alkalizer  of  the  blood  and  of  the  urine,  of  a  solvent  for 
uric  acid,  and  of  a  diuretic. 

Its  physiological  and  toxic  effects  closely  resemble,  but  are 
supposed  to  exceed,  those  of  potassium.  It  is  a  depressant 
to  the  tissues,  particularly  to  those  of  the  heart  and  nervous 
system.  This  circumstance  accounts  for  its  relatively  small 
therapeutic  dose.  The  carbonate  taken  in  larger  quantity 
than  45  grains  a  day  was  found  by  Charcot  to  set  up 
dyspepsia.  Various  nervous  symptoms  have  from  time 
to  time  been  observed  during  its  administration.  Garrod 
mentions  slight  tremor  in  one  hand  in  two  cases  with 
unsound  kidneys,  and  twitchings  in  both  arms  in  another 
patient  taking  very  large  doses. 

The  therapeutical  results  obtained  by  Garrod  included, 
besides  diuresis  and  alkalization  of  the  urine,  with  disap- 
pearance of  gravel,  a  marked  immunity  from  the  recur- 
rence of  gouty  attacks,  and,  as  reported  by  the  patient,  a 
reabsorption  of  gouty  concretions.  It  should  be  borne  in 
mind  that  the  mode  of  administration  in  considerable 
dilution,  which  has  been  adopted  at  Garrod's  original 
suggestion,  is  in  itself  a  remedial  measure. 

25 


386  THE  SALTS  OF  LITHIUM 

Whilst  confirming  Garrod's  observations  as  to  the 
immediate  diminution  in  the  amount  of  uric  acid  excreted, 
Lecorche*  is  unable  to  corroborate  his  statement  as  to 
the  strong  diuretic  and  alkalizing  effect  of  lithium  salts. 
In  neither  of  the  two  cases  of  which  an  accurate  observa- 
tion was  made  was  there  any  permanent  diuresis ;  in  one 
of  them  even  temporary  diuresis  failed  to  occur.  Daily 
doses  of  15  and  of  30  grains  of  the  carbonate,  whilst  de- 
pressing the  acidity,  did  not  produce  an  alkaline  reaction 
of  the  urine.  He  also  finds  that  urea  and  phosphoric 
acid  are  markedly  diminished  in  the  urine,  as  well  as  the 
uric  acid.  The  alkaline  bases  (potassium  and  sodium)  are 
also  diminished,  but  more  particularly  calcium  and 
magnesium. 

Sir  W.  Roberts  states,  in  connection  with  lithium  car- 
bonate and  piperazin,  that  '  they  do  not  confer  upon  blood 
serum  or  synovia  (when  added  to  them  in  o'l  per  cent,  to 
o"2  per  cent,  solutions)  the  slightest  help  in  dissolving 
sodium  biurate,  nor  in  retarding  its  precipitation.  Their 
beneficial  effect,  if  it  exists,  is  not  to  be  traced  to  their 
solvent  power  on  sodium  biurate.' 

These  discrepancies  called  for  a  renewed  investigation 
of  the  pharmacology  of  lithium.  The  same  need  is  yet 
more  strongly  indicated  by  the  recent  criticism  of  Dr. 
Haig,i-  who  also  finds  that  lithia  diminishes  the  excretion 
of  uric  acid.  This  is  in  apparent  contradiction  with  Sir 
A.  Garrod's  opinion  that  urate  of  lithium  is  one  of  the 
most  soluble  of  the  urates,  and  Haig  suggests  an  explana- 
tion. He  states  that  lithia  given  by  the  mouth  is  of  no 
use  as  a  solvent  for  uric  acid,  because,  as  shown  by  Rose,  J 
it  forms  a  nearly  insoluble  triple  phosphate  with  phosphate 
of  sodium,   or  with  the  triple  phosphates  of  ammonium 

*  Loc.  ci'L,  p.  557  el  scq.  t  Loc.  ciL,  pp.  29,  2,0. 

X  '  Chemical  Analysis,' p.  15. 


THE  SALTS  OF  LITHIUM  387 

and  sodium,  salts  which  are  generally  present  in  animal 
fluids.  Even  if  this  were  to  receive  a  further  experimental 
confirmation,  it  would  not  prove  conclusively  that  the 
salts  of  lithium  are  inert.  We  possess  abundant  evidence 
that  some  of  the  most  insoluble  substances  undergo 
partial  solution  in  the  organism.  A  fortiori  might  this 
result  be  expected  in  the  case  of  a  body  many  of  the  com- 
binations of  which,  and  in  particular  the  urate,  are  ex- 
tremely soluble.  On  the  other  hand,  this  would  go  far  to 
explain  the  diverging  estimates  which  have  been  formed 
of  its  specific  utility  in  gout.  Taken  in  conjunction  with 
the  fact  that,  in  spite  of  the  experimental  demonstration 
of  the  unequalled  solubility  of  lithium  urate,  upon  which 
such  fair  hopes  had  been  founded,  lithium  has  not  secured, 
after  a  prolonged  trial,  a  leading  position  in  the  treatment 
of  gout,  the  suspicion  which  has  been  thrown  upon  the 
genuineness  of  its  most  valuable  medicinal  property  leaves 
us  in  an  attitude  of  reserve.  We  are  bound  to  take  heed 
of  the  relative  failures  which  have  been  reported  by  various 
clinical  observers ;  but  we  cannot  lose  sight  of  the  favour- 
able testimony  supplied  by  others  and  by  the  patients 
themselves. 

The  question  is  whether  these  salts  may  not  be  capable 
of  very  different  activities  under  varying  circumstances 
and  in  different  subjects.  On  the  other  hand,  the  limita- 
tions due  to  their  toxicity  make  it  probable  that  we  have 
already  gauged  the  range  of  their  usefulness. 

THE  SALTS  OF  AMMONIUM. 

Ammonia  and  its  salts  enjoyed  among  the  ancients  a 
reputation  which  has  not  been  maintained.  The  disuse 
into  which  they  have  lapsed  is  partly  due  to  the  acknow- 
ledged superiority  of  the  salts  of  the  fixed  alkalies.     It  is 


THE  SALTS  OF  AMMONIUM 


justified  on  chemical  grounds  by  the  circumstance  that 
ammonia  is  not  excreted  as  an  alkah,  but  as  nitric  acid. 
It  increases  the  acidity  of  the  urine,  and  cannot,  therefore, 
be  regarded  as  a  solvent  of  gravel.  Sir  W.  Roberts  has 
shown  that  its  salts  do  not  possess  solvent  power  for  the 
biurate  of  sodium,  but  rather  check  its  solubility  in  more 
favourable  media  to  which  they  may  have  been  added. 
His  results  are  at  variance  with  the  statements  formerly 
made  by  Garrod,  that  ammonium  phosphate  possesses 
considerable  solvent  power  for  sodium  biurate. 

Buckler,*  to  whom  a  revival  of  the  ammoniacal  treat- 
ment was  due,  thought  that  he  had  retarded  in  thirteen 
patients,  by  the  administration  of  ammonium  phosphate,  a 
return  of  the  gouty  attack,  and  that  he  had  also  taken 
some  effect  on  the  concretions.  S.  Edwardsf  also  advo- 
cated its  use,  on  the  ground  that  the  neutral  phosphate 
would  give  rise  to  a  soluble  ammonium  urate,  and  recom- 
mended that  from  120  to  150  grains  should  be  given  each 
day. 

Sir  A.  Garrod  declared  himself  well  satisfied  with  the 
results  obtained  from  this  salt  in  cases  of  chronic  gout. 

Although  we  cannot  now  attribute  a  specific  value  in 
gout  to  any  of  the  ammoniacal  salts,  their  general 
properties  are  eminently  serviceable  in  the  treatment  of 
the  various  ailments  of  gouty  patients.  As  stimulants, 
as  diaphoretics,  and  as  diuretics,  they  will  be  found 
useful. 

The  ammonium  chloride  deserves  special  mention  as  an 
important  hepatic  stimulant  and  cholagogue,  and  also  as 
a  valuable  remedy  in  some  forms  of  neuralgia  to  which 
the  gouty  are  liable.  In  these  various  capacities  it  will 
probably  receive  more  attention  in  connection  with  gout 

*  Amer.  Jour,  of  Med.  Sc,  January,  1846,  quoted  by  Lecorchd. 
t  Land.  Med.  Gas.,  June,  1850,  quoted  by  Lecorche. 


THE  SALTS  OF  CALCIUM  AND  OF  MAGNESIUM     389 

than  has  hitherto  been  awarded  to  it.  In  common  with, 
but  in  a  higher  degree  than,  the  other  salts  of  ammonium, 
it  is  credited  with  the  power  of  increasing  the  output  of 
urea  and  of  uric  acid.  Ammonia  itself  has  been  suspected 
of  entering  into  the  formation  of  these  bodies. 


THE  SALTS  OF  CALCIUM  AND  OF  MAGNESIUM. 

It  will  not  be  necessary  to  dwell  long  on  the  therapeutic 
action  of  these  substances  in  gout.  Their  great  reputation 
was  anterior  to  the  full  appreciation  of  the  stronger  claims 
of  the  alkaline  salts ;  but  they  have  preserved  an  im- 
portant place  in  practice,  and  are  to  the  present  day 
largely  used,  and  with  considerable  benefit,  although  we 
cannot  boast  of  any  accurate  knowledge  of  their  mode  of 
action. 

The  chemical  properties  of  the  two  sets  of  salts  present 
many  points  of  resemblance  with  well-marked  differences, 
especially  as  regards  their  solubility. 

The  physiological  actions  differ  widely,  calcium  salts  being 
astringent,  and  magnesium  salts  purgative.  In  some 
respects  they  agree.  Reference  to  Bouchard's  table  of 
toxicity*  will  show  that  in  their  toxic  equivalent  they  are 
not  far  apart,  magnesium  being  twice  as  poisonous  as 
calcium,  though  much  more  likely  to  be  quickly  eliminated  ; 
and  that  they  approach  much  more  closely  the  potassium 
salts  than  the  salts  of  sodium. 

Of  their  intimate  actions  on  the  tissues  we  know 
nothing.  Lauder  Bruntonf  and  Cash  have  shown  that 
calcium  does  not  regularly  increase  the  contractile  power 
of  muscle,  but,  like  sodium,  increases  the  duration  of  the 
contraction,  and  the  muscular  viscosity  or  contracture  • 
the  latter  is  enormously  increased  by  barium ;  whilst 
*  C/.Y).  378.  ~     t  J^o^-  at.,  p.  1 10. 


390     THE  SALTS  OF  CALCIUM  AND  OF  MAGNESIUM 

potash  diminishes  both.  On  the  vessels  calcium,  mag- 
nesium and  barium  produce  contraction,  though  in  much 
less  a  degree  than  potassium  chloride.  On  the  excised 
heart  of  the  frog  artificially  fed  by  saline  solution,  the 
addition  of  minute  quantities  of  chloride  of  calcium  pro- 
longs the  contractions,  which  can  be  restored  to  their 
normal  length  by  a  trace  of  potash,  without  any  of  the 
weakening  effects  being  then  induced  which  are  special  to 
the  latter. 

The  therapeutic  virtues  common  to  both  in  gout  are, 
so  far  as  known,  chiefly  their  antacid  and  diuretic  pro- 
perties. Calcium  is  chiefly  excreted  by  the  bowel ;  so  is 
magnesium  when  it  purges,  but  in  non-purgative  doses  it 
passes  out  through  the  kidneys,  acting  as  a  diuretic  as 
well  as  an  antacid.  The  diuretic  action  of  calcium  is 
largely  due  to  the  copious  dilutions  in  which  it  is  usually 
administered  in  gout. 

The  salts  of  calcitmi  have  undoubtedly  been  used  with 
good  results  in  gout.  In  reviewing  this  subject,  Lecorche 
accepts  Lieutaud  and  Morand's  experimental  conclusions 
to  the  effect  that  Miss  Stephens'  remedy  (soap  and  egg- 
shells) owed  its  efficacy  to  bicarbonate  of  lime.  Subse- 
quent experiments  were  conducted  by  Holly,  who  arrived 
at  the  same  conclusion.  Later  Whytt  succeeded  in 
curing  the  gravel  by  the  administration  of  one  to  two 
pints  of  lime-water,  continued  daily.  The  same  treat- 
ment prevented  the  return  of  the  gout  in  a  patient  who 
had  suffered  from  severe  and  recurrent  attacks.  Lecorche 
also  refers  to  Gilbert  Blanc's  observation  of  a  lengthening 
of  the  intervals  during  its  use. 

The  beneficial  effects  of  calcareous  mineral  waters,  such 
as  those  of  Contrexeville,  Vittel,  Capvern,  Pougues,  etc., 
which  contain  chiefly  lime,  are  too  well  attested  to  admit 
of  doubt.     In  presence  of  the  fact  that  urate  of  calcium 


THE  SALTS  OF  CALCIUM  AND  OF  MAGNESIUM    391 

is  highly  insoluble,  it  is  difficult  to  explain  them  on  the 
lines  of  the  uratic  theory  of  gout.  We  shall  return  to 
their  consideration  when  discussing  the  uses  of  mineral 
waters.  We  should  not  lose  sight  of  the  sedative  action 
of  weak  solutions  of  lime  on  the  alimentary  mucous  mem- 
brane, and  of  their  solvent  power  for  mucus,  in  addition 
to  the  antacid  and  diuretic  properties  which  we  have 
dwelt  upon. 

The  salts  of  magnesium  probably  possess  greater  value 
than  the  prevailing  plethora  of  minor  remedies  for  gout 
gives  us  a  chance  of  realizing.  On  this  point  earlier 
observations  might  be  consulted  with  advantage,  Brande* 
narrates  how  a  patient  whose  gastric  symptoms  had  led 
to  the  use  of  magnesia  ceased  to  observe  uric  acid  in  the 
urine,  and  remained  free  from  gout  for  a  longer  period 
than  during  any  of  the  six  previous  years.  Scudamore 
also  believed  in  the  efficacy  of  magnesia  or  of  magnesium 
carbonate,  although  he  objected  to  the  constant  daily 
'  employment  of  alkalies  on  the  simple  principle  of  pre- 
venting gout.' 

Few  gouty  patients  at  the  present  day  have  never 
experienced  in  some  form  or  other  the  benefit  of  this 
medication.  The  black  draught  and  the  white  mixture 
seldom  fail  to  relieve,  and  their  magnesian  constituents 
and  the  milder  citrate  form  the  basis  of  various  aperient 
salts  largely  used  under  different  names.  Again,  many 
laxative  mineral  waters,  such  as  those  of  Carlsbad  and 
of  Marienbad,  are  largely  indebted  to  magnesium  for  their 
efficacy  in  gout. 

We  are  as  ignorant  of  the  nature  of  any  intimate 
influence  which  may  be  exerted  by  these  salts  on  the 
tissues  as  in  the  case  of  those  of  calcium.     The  obvious 

*  EdinHirgh  Med.  Pliys.  Essays,  iii;,  p.  450,  quoted  by  Lecorche. 


392  SOME  RECENT  ALKALIZING  REMEDIES 


results  are  traceable  to  their  combined  purgative,  antacid 
and  diuretic  properties.  Magnesia  itself  and  its  carbonates 
exercise  in  addition  a  powerful  check  upon  the  acidity  of 
the  stomach,  and  in  some  cases  of  gouty  dyspepsia  and 
gastralgia  they  are  sovereign  remedies. 

SOME  RECENT  ALKALIZING  REMEDIES. 

The   chief  representatives    of  this   group    of  powerful 

organic  alkalies  are   piperazin,   lysidin,   and  lycetol.     In 

virtue  of  their  extraordinary  neutralizing  power  for  acids, 

great   results   were   expected   of  their   administration   in 

gout.     These  hopes  have  not  been  realized.     Favourable 

accounts*  of  their  employment  are  hitherto  too  few  to 

establish  their  reputation. 

Lysidin,'f 

CHg.NHvC.CHs 

CHg.N, 

possessing  five  times  the  alkalizing  and  the  uric  acid 
solvent  power  of  piperazin,  is  a  hygroscopic,  reddish-white 
soluble  powder,  the  taste  of  which  is  said  to  recall  the 
smell  of  mice.  It  is  obtained  as  a  hydrochlorate  by  the 
dry  distillation  of  ethylene-diamine-hydrochlorate  with 
sodium  acetate.  Its  much  greater  strength  as  a  solvent 
renders  any  further  reference  to  the  weaker  solvent 
piperazin  unnecessary. 

E.  Grawitz,J  who  administered  in  increasing  doses 
from  I  to  5  grammes  of  lysidin  daily  to  two  patients  with 

*  C/.  Heermann  {Therap.  Monatsch.^  i894)  viii.,  p.  561),  Mapother 
{Practitioner.,  1894,  p.  265),  and  Biesenthal  (Virch.  'Arch.,'  1894, 
cxxxvii.,  p.  31) — quoted  in  the  Year-Book  of  Treatment,  1895,  pp.  126, 
127 — speak  favourably  of  piperazin. 

t  These  data  are  supplied  by  Dr.  A.  Garrod  in  the  Year-Book  of 
Treatment  for  i  S96. 

%  Deiitsch.  Med.  Wochettsch.,  1894,  xx.,  p.  786. 


SOME  RECENT  ALKALIZING  REMEDIES  393 

tophaceous  gout,  reports  definite  results,  such  as  a  marked 
diminution  of  the  tophi  on  the  epiglottis  and  in  the 
neighbourhood  of  the  joints,  and  a  marked  improvement 
in  the  mobility  of  the  joints.  But,  in  common  with  other 
observers,  he  failed  to  obtain  any  evidence  of  an  increase 
or  of  a  diminution  in  the  excretion  of  uric  acid,  and  he 
w^as  driven  to  the  conclusion  that  a  portion  only,  if  any, 
of  the  uric  acid  from  the  tophi  was  excreted  by  the  kidneys 
as  such. 

G.  Klemperer  and  A.  von  Zeisig*  treated  three  typical 
cases  of  gout  with  lysidin,  but  were  unable  to  trace  any 
influence  on  the  symptoms,  or  on  the  excretion  of  uric 
acid. 

Sir  W.  Roberts  had  demonstrated  the  failure  of  piperazin 
to  assist  blood  serum  or  synovia  in  dissolving  sodium 
biurate  or  in  delaying  its  precipitation.  Martin  Mendel- 
sohn,f  to  whom  we  owe  the  observation  that  the  uric  acid 
solvent  power  of  piperazin  and  of  lysidin  is  abolished  by 
the  smallest  admixture  of  urine  owing  to  the  sodium 
chloride  it  contains,  is  of  opinion  that  gouty  tophi  may 
perhaps  be  dissolved  by  these  agents,  and  states  that  uric 
acid  is  dissolved  by  them  in  serum  nearly  as  well  as  in 
water.  This  view  does  not  appear  to  be  compatible  with 
Sir  W.  Roberts'  statement  concerning  piperazin.  At  any 
rate,  they  are  obviously  powerless  to  effect  the  solution  of 
any  concretions  within  the  urinary  tract. 

Lycetol  (dimethyl  -  piperazin  -  tartrate)  has  been  well 
spoken  of  by  Wittzach,;}:  who  obtained  good  results  in  a 
case  of  gout.  It  is  stated  to  be  equal  in  power  to  piperazin, 
not  hygroscopic,  and  pleasant  to  the  taste. 

*  Zeitsch.f.  Kim.  Med.,  1895,  xxvii.,  p.  558. 
t  Deutsch.  Med.  Wochensch.,  1895,  xxi.,  p.  283. 
X  Allg.  Med.  Cent.  Zg.,  1894,  No.  7  ;  and  Therafi.  Monatssck.,  1895, 
p.  387. 


394  SOME  RECENT  ALKALIZING  REMEDIES 

Uricedin  is  said  to  be  a  mixture  of  salts  (the  citrate, 
chloride,  and  sulphate  of  sodium,  and  the  citrate  of 
lithium).  Meisels  reports  that  it  does  not  display  the 
power  possessed  by  pipera^in  of  preventing  the  deposition 
of  urates  in  the  tissues  of  birds  after  the  subcutaneous 
injection  of  potassium  chromate.  In  man,  far  from  in- 
creasing, it  rather  diminishes  the  excretion  of  uric  acid. 
It  does  not  appear,  according  to  his  observations,  to  be 
entitled  to  a  place  among  the  solvents  for  uric  acid. 


CHAPTER  XLIII. 

THE    SALICYLATES    AND    OTHER    REMEDIES 
IN   GOUT. 

SODIUM  SALICYLATE  AND  THE  SALICYLIC  GROUP. 

The  uncertainty  which  still  prevails  as  to  the  value  of 
these  substances  in  gout  is  shown  by  the  fact  that  some 
recent  writers  on  pharmacology  do  not  mention  gout 
among  the  affections  for  which  they  are  of  use,  and  others 
even  describe  them  as  useless.  On  the  other  hand,  among 
writers  on  gout  they  have  found  some  strenuous  sup- 
porters. 

The  members  of  this  group  to  which  we  should  devote 
attention  are  the  salicylates  of  sodium,  of  quinine  and  of 
lithium,  salicin,  and  saligenin. 

Salicylic  acid  (HC7H5O3),  obtained  from  the  salicylates 
contained  in  the  oils  of  wintergreen  and  of  sweet  birch, 
is  also  artificially  prepared  by  combining  carbonic  acid 
gas  with  carbolic  acid,  a  much  less  trustworthy  source. 
Its  salts  only  are  employed  in  gout. 

Salicin  (C13H18O7),  a  glucoside  obtained  from  the  bark  of 
the  willow  and  of  the  poplar,  is  not  largely  used,  its 
action  being  less  powerful,  though  it  is  said  to  be  better 
sustained  and  less  depressing  to  the  heart  and  vascular 
system. 

Saligenin    (CrHgOo)   is   produced   from    salicin   by   the 


396     SODIUM  SALICYLATE  AND  THE  SALICYLIC  GROUP 

separation  of  glucose.  It  has  been  recently  tried  by- 
Walter,*  who  reports  good  results  from  its  use. 

The  salicylates  of  quinine  and  of  lithium  are  usually  ad- 
ministered in  doses  too  small  to  bring  the  salicylic  radical 
into  action,  though  they  may  do  good  service  through 
their  basic  constituent. 

Sodium  salicylate,  the  preparation  almost  invariably 
prescribed,  behaves  in  the  same  way  as  salicylic  acid,  part 
of  which  combines  in  the  blood  or  in  the  tissues  with 
glycocine  to  form  salicyluric  acid — 

H  QHgOa  +  C2H5N  O2  =  H  CyH8N04  +  H2O— 

another  part  being  discharged  as  salicylate  by  the  kidneys. 
Salicin   undergoes  decomposition  in  the  bowel  and  in 
the  blood  into  saligenin  and  glucose : 

ClsHjgOy  +  H2O  =  CgHi206+  C7H8O2. 

Saligenin  is  itself  broken  up  into  salicylous  (HC7H5O2), 
salicylic,  and  salicyluric  acids. 

These  reactions  supply  an  explanation  for  the  increased 
acidity  induced  in  the  urine,  and  may  also  account  for  the 
irritation  sometimes  set  up  in  the  kidneys,  which  often 
leads  to  alhuminuvia,  and  sometimes  to  hcsmaturia. 

The  physiological  action  is  exerted  on  the  heart  and 
lungs,  lowering  pulse-rate  and  blood-pressure,  and  likewise 
the  respiration,  the  arrest  of  which  is  the  immediate 
cause  of  death. 

Delirium,  tinnitus,  deafness,  giddiness,  and  headache 
are  the  results  of  its  action  on  the  central  nervous  system, 
but  the  peripheral  nerves  are  not  affected.  According  to 
Lauder  Brunton,  collapse  may  sometimes  be  induced  by 
sudden  depression  of  the  circulation.     The  stage  of  de- 

*  C/.  Year- Book  of  Treatment^  1896  ;  and  Therap.  Monatsch., 
January  and  April,  1895. 


SODIUM  SALICYLATE  AND  THE  SALICYLIC  GROUP     397 


pression  is  preceded  by  increased  cardiac  action,  flushing, 
perspiration,  and  fulness  in  the  head  (Mitchell  Bruce). 

Therapeutic  Action. — The  antipyretic  power  of  the  drug 
may  be  connected  with  its  germicidal  power ;  both  of 
them  are  hitherto  unexplained.  It  is  noteworthy  that 
the  normal  temperature  is  not  appreciably  lowered.  The 
relief  of  artictdar  pain,  so  remarkable  in  acute  rheumatism, 
is  also  without  an  explanation.  One  of  the  most  im- 
portant virtues  of  salicylic  acid  is  its  cholagogue  action, 
which  differs  from  that  of  other  agents  in  increasing  the 
fluid  instead  of  the  sohd  constituents  of  bile  (Lauder 
Brunton),  a  circumstance  which  suggests  its  employment 
in  cases  of  biliary  sedimentation.  Another  not  unimportant 
action  is  the  inhibition  of  the  later  stages  of  pancreatic 
digestion,  indol  and  skatol  not  being  formed  in  its  presence. 

The  Action  of  Salicylates  in  Gont. — The  affinity  which 
undoubtedly  exists  between  rheumatism  and  gout  con- 
tains the  suggestion  that  an  agent  so  powerful  in  the 
former  should  not  be  inoperative  in  the  latter.  That  it 
is  really  useful  in  gout  has  been  and  is  held  by  many  good 
observers,  but  between  them  there  is  much  difference  of 
opinion  as  to  the  degree  of  relief  obtained,  and  as  to  the 
stages  suitable  for  this  medication. 

Germain  See,*  who  was  an  early  advocate  of  salicylates, 
considered  them  superior  to  colchicum,  and  not  predis- 
posing, Hke  the  latter,  to  chronic  gout — in  a  word,  as 
valuable  as  in  acute  rheumatism. 

Barclayt  was  satisfied  that  they  did  not  act  so  quickly 
as  in  acute  rheumatism,  nor  so  well  in  gout  as  colchicum. 
He  thought,  however,  that  salicylate  of  sodium  might  be  of 
use  where  colchicum  lost  its  effect,  or  in  cases  originally 
rheumatic. 

*  Progrh  Medical,  1877,  p.  745,  quoted  by  Duckworth. 
t  '  St.  George's  Hospital  Reports,'  vol.  ix.,  1877-78. 


398     SODIUM  SALICYLATE  AND  THE  SALICYLIC  GROUP 

Duckworth  finds  it  inferior  for  the  relief  of  the  urgent 
symptoms,  and  thinks  that  most  physicians  agree  with 
him  in  this  ;  but  in  a  few  cases  where  colchicum  failed 
com.pletely,  marked  benefit  was  obtained. 

Among  the  many  supporters  of  the  salicylic  treatment 
of  gout,  including  Latham,  Ralfe,  Lecorche,  and  Bouchard, 
none  has  expressed  so  strong  a  belief  in  the  drug  as  Haig, 
who,  holding  that  rheumatism  and  gout  are  due  to  the 
same  cause,  excess  of  uric  acid,  concludes  that  they  must 
be  both  amenable  to  the  same  remedy  so  long  as  it 
disposes  of  the  offending  principle. 

Noel  Paton*  has  reported  a  diminution  in  the  uric  acid 
excreted,  in  opposition  to  the  results  of  Lecorche  and 
of  Haig,  who  found  an  increase  in  the  uric  acid. 

According  to  Lecorche,-|-  it  tempers  the  severity  of  the 
acute  attack  and  lessens  the  pain,  but  does  not  shorten 
the  malady,  as  it  does  in  rheumatism.  In  chronic  gout 
its  use  much  increases  the  uric  output.  Tophi  have  been 
noticed  to  disappear ;  but  the  action  is  more  marked  on 
cartilaginous  and  ligamentous  infiltrations. 

The  rationale  suggested  by  Lecorche^  rests  upon 
analyses  made  in  cases  of  rheumatic  fever,  which  show 
a  considerable  excess  in  the  excretion  of  urea,  uric  acid, 
and  phosphoric  acid. 

Lecorche  believes  that  it  gives  a  stimulus  to  the  vitality 
of  organic  cells,  and  to  the  '  disassimilation  '  of  the  nitro- 
genous substances,  thus  acting  in  a  manner  opposed  to 
that  of  the  alkaline  bicarbonates  and  sulphates. 

His  doses  are  4  to  6  grammes  a  day.     And  in  chronic 

*  Journal  of  Anatomy  and  Physiology^  January,  1886,  pp.  26-32, 
quoted  by  Duckworth. 

t  Loc.  di.,  p.  583. 

%  Lecorchd  et  Talamon,  '  Action  du  Salicylate  de  Soude  sur  I'ur^e, 
I'acide  urique  et  I'acide  phosphorique  de  Purine  dans  le  rhumatisme 
articulaire  aigu'  {Revue  Mensuelle  de  Med.,  Fev.,  1880). 


SODIUM  SALICYLATE  AND  THE  SALICYLIC  GROUP     399 

gout  with  visceral  trouble  (except  interstitial  nephritis) 
he  continues  this  treatment  for  months,  with  a  few  days' 
interval  after  each  fortnight,  thus  departing  from  the 
practice  of  G.  See,^  who  used  3  drachms  daily  for  three 
days,  then  2  drachms  for  three  days,  and  repeated 
alternately  the  same  periods  and  doses  for  three  weeks. 

He  noticed  that  the  increased  excretion  of  urea,  phos- 
phoric and  uric  acid  began  after  one  or  two  days,  and 
lasted  for  three  or  four  days. 

Duckworth,  whilst  not  regarding  salicylate  of  sodium  as 
likely  to  supersede  colchicum,  recognises  its  value,  which 
he  attributes  to  the  cholagogue  and  vascular  depressing 
property  which  it  possesses,  and  to  its  chemical  inter- 
ference with  the  formation  of  uric  acid.  Its  mode  of 
action  is  sometimes  prompt  and  decided ;  but  usually  it 
does  not  give  relief  so  rapidly  as  colchicum,  and  not  for 
a  day  or  two  in  any  degree  appreciable  to  the  patient. 

Haig's  views  deserve  special  attention.  His  high 
opinion  of  sodium  salicylate  rests  upon  the  fact  that, 
whereas  other  acids  render  uric  acid  less  soluble,  salicylic 
acid  removes  it  as  a  soluble  salicylurate,  salicyluric  acid 
being  more  soluble  than  uric  acid. 

'  Thus,  salicylates  probably  clear  urates  out  of  the  blood 
without  allowing  them  to  do  harm  in  passing  through, 
and  they  thus  free  the  blood  from  uric  acid,  and  allow 
the  blood  decimal  to  rise.'f  Acute  gout  supervening  in 
the  night  is  quickly  relieved  by  salicylate  of  sodium  if 
given  in  sufficient  doses.  '  In  rheumatism  the  doses  ad- 
ministered are  large  and  frequent — 20  grains  every  two 
hours — why  not  in  gout  ?  In  those  cases  in  which  the 
pain  is  of  a  traumatic  and  surgical  kind,  as  when  due  to 
excessive  exercise,  salicylates  are  found  to  be  useless ; 
rest  and  fomentation  are  the  remedies.' 

*  €/.  Duckworth,  /oc.  cit.^  p.  358.  t  Loc.  cii.,  p.  42. 


400     SODIUM  SALICYLATE  AND  THE  SALICYLIC  GROUP 

According  to  Haig,*  salicylates  produce  a  considerable 
secretion  of  uric  acid  during  the  first  and  second  days, 
but  the  amount  of  this  initial  output  is  never  again 
reached.  Subsequent  quantities  show  oscillations,  but 
tend  to  approach  the  normal  proportion  to  urea,  and 
sink  below  it  as  soon  as  the  drug  is  stopped.  After  the 
suspension  of  the  drug,  retention  of  uric  acid  again  takes 
place  into  the  tissues,  whence  salicylic  acid  had  removed 
it  at  first  with  great  ease,  and  subsequently  in  diminishing 
quantities. 

Haig  lays  stressf  on  the  fact  that  salicyluric  acid 
formed  by  the  action  of  the  drug  on  uric  acid  is  much 
more  soluble  in  slightly  acid  than  in  alkaline  or  neutral 
fluids. 

The  Limitations  of  the  Salicylic  Treatment,  and  its  Contra- 
indications.— The  weight  of  the  arguments  thus  ably  set 
forth  no  impartial  judge  will  fail  to  admit.  We  are 
unable,  however,  to  adopt  without  reservation  the  con- 
clusion towards  which  they  tend.  Even  were  salicylate 
of  sodium  to  justify  on  further  trial  Haig's  estimate  of  its 
power  to  check  acute  gouty  arthritis  when  administered 
in  sufficiently  large  doses,  its  employment  in  that  affec- 
tion must  remain  much  more  limited  than  in  acute 
rheumatism. 

Rheumatic  arthritis  itself  is  far  from  being  always 
amenable  to  its  administration ;  we  frequently  meet  with 
cases  in  which  for  unknown  reasons  the  salicylate  fails 
to  relieve  even  when  combined  with  alkalizing  doses  of 
potassium  bicarbonate.  Disappointment  may  be  ex- 
pected with  yet  greater  frequency  in  gout,  the  clinical 
history  of  which  is  made  up  of  idiosyncrasies.  We  do 
not  therefore  venture  to  anticipate  here  the  same  propor- 
tion of  success  as  among  the  rheumatic. 

*  Lot.  a'/.,  p.  56.  t  Loc.  d/.,  p.  19. 


SODIUM  SALICYLATE  AND  THE  SALICYLIC  GROUP    401 


Were  gout  chiefly  prevalent  among  young  adults  with 
sound  tissues  and  pliable  vaso-motor  mechanisms,  the 
treatment  in  question  might  be  more  widely  applicable. 
The  class  we  have  to  deal  with  is  the  opposite,  and 
demands  the  greatest  caution  in  the  use  of  remedies. 
This  is  fully  recognised  by  such  warm  advocates  of 
salicylates  as  Latham,  Bouchard,  and  Lecorche. 

Whilst  renal  susceptibility  is  the  weak  point  in  gout, 
renal  irritation  is  the  chief  danger  to  be  feared  from 
salicylates.  Here,  then,  is  a  major  contra-indication  which 
excludes  all  those  subjects  in  whom  the  kidney  is  not 
absolutely  sound.  Many  others  are  under  a  strong  sus- 
picion of  renal  instability  ;  to  this  group  belong  patients 
presenting  a  high  pulse  tension  and  occasional  albu- 
minuria. A  minor  contra-indication  exists  in  connection 
with  them,  and  we  should  not  lightly  submit  them  to  the 
risk  of  large  doses.  There  remains  a  limited  number,  the 
selected  few,  in  whose  soundness  we  may  feel  the  neces- 
sary confidence.  Yet  even  here  we  cannot  feel  sure  of 
the  result.  In  acute  gout  all  heroic  treatment  is  a  risk. 
Too  sudden  a  relief  by  internal  medication  may  lead  to 
the  same  complication  as  sudden  revulsion  by  outward 
treatment,  and  experience  shows  that  both  lithium  and 
the  salicylates  are  not  free  from  this  form  of  danger.  In 
short,  the  treatment  of  acute  gout  by  large  doses  of  the 
latter  must  still  be  regarded  as  experimental,  even  in 
those  cases  in  which  it  is  admissible,  and  on  no  con- 
sideration should  any  but  the  '  natural '  preparation  be 
prescribed.  Meanwhile,  a  modified  treatment  of  the 
acute  attack  by  relatively  small  doses  of  sodium  salicylate 
has  been  widely  adopted  by  practitioners,  with  results 
which  are  reported  as  satisfactory. 

When  applied  to  chronic  gout  or  to  goutiness,  the 
medication  in  question  is  free  from  the  chief  objections 

26 


402  BENZOIC  ACID  AND  ITS  SALTS 

which  we  have  urged.  Large  doses  are  not  so  much 
required  as  perseverance  in  the  use  of  the  smaller  supplies. 
Time  is  not  a  consideration.  Each  case  can  be  studied 
at  leisure.  An  intolerance  of  the  remedy  is  disclosed 
before  harm  has  resulted.  And,  lastly,  an  intermittent 
administration  may  procure  the  benefits  of  the  treatment 
without  any  of  its  disadvantages.  In  this  form  the 
salicylic  treatment  is  of  much  value,  and  is  favourably 
endorsed  with  the  personal  testimony  of  patients  belong- 
ing to  the  profession. 

BENZOIC  ACID  AND  ITS  SALTS. 

The  chemical  behaviour  and  the  mode  of  action  oi 
benzoic  acid  closely  resemble  those  of  salicylic  acid.  It 
shares  with  the  latter  the  property  of  enabling  any  excess 
of  nitrogen  to  be  voided  in  acid  tirine  as  a  soluble  organic 
salt  instead  of  in  the  shape  of  insoluble  urates.  Whilst, 
therefore,  its  acidifying  power  renders  it  of  use  in  the 
treatment  of  vesical  troubles  associated  with  alkaline  urine, 
it  claims  to  be  a  valuable  evacuant  for  the  elements  of  uric 
acid  in  gout,  especially  valuable  in  those  atonic  forms 
where  the  administration  of  alkalies  is  undesirable. 

As  in  the  instance  of  salicylic  acid,  glycocine,  which  is 
regarded  as  a  factor  immediately  concerned  in  the  forma- 
tion of  uric  acid,  enters  into  combination  with  benzoic 
acid  : 

C7H602+C2H5N02  =  C9H9N03  +  H20. 

The  result  is  hippuric  acid,  the  salts  of  which  are  soluble. 
On  the  strength  of  this  chemical  fact,  and  of  the  theory 
based  upon  it,  the  benzoates  have  been  much  used  with 
apparently  satisfactory  results.  The  ammonium  benzoate 
gives  the  maximum  acidifying  effect  ;  but  in  gout  the 
potassium  and  the   sodium    benzoates  will    be   found    more 


BENZOIC  ACID  AND  ITS  SALTS  403 

suitable.     Their  administration  has  been  strongly  advo- 
cated in  this  country  by  Sir  A.  Garrod. 

Sodium  benzoate  had  also  been  recommended  by  Ure, 
Simonet,  and  Chalvet,  Bence  Jones,  Rene  Brian,*  and 
Rukenf  (Lecorche).  With  the  administration  of  benzoate 
of  lithium  Lecorche  found  a  diminution  in  the  uric  acid 
excretion  from  0*70  to  0*30,  and  in  another  case  from  0'65 
to  0'28. 

Duckworth  has  likewise  prescribed  the  lithium  salt  of 
benzoic  acid,  sometimes  beneficially  in  chronic  gout,  in 
doses  of  from  8  grains  to  ^  drachm,  and  in  combination 
with  tincture  of  nux  vomica.  He  reminds  us  of  a  valuable 
suggestion  made  by  Golding  Bird  to  combine  with  the 
benzoates  the  administration  of  phosphate  of  sodium. 

Under  the  benzoic  treatment  a  general  improvement 
and  a  relative  immunity  from  attacks  have  often  been  re- 
ported. 

Whether  these  results  are  to  be  attributed  to  the 
chemical  influence  which  has  been  suggested,  or  to  some 
other  mode  of  action,  must  remain  for  the  present  un- 
decided. 


IODINE,  SULPHUR,  ARSENIC,  AND  MERCURY. 

These  bodies  belong  to  the  group  of  alteratives  ;  their 
special  function  in  therapeutics  is  concerned  with  meta- 
bolism, and  in  that  capacity  they  are  likely  to  be  of  service 
in  an  affection  such  as  gout,  which  may  be  regarded  as  a 
deviation  from  the  healthy  type  of  nutrition.  In  reality 
they  are  of  great  value,  especially  in  constitutional  gout  or 
goutiness.     We  need  not  dwell  in  any  detail  upon  their 

*  '  Traitement  de  la  Goutte  par  les  Benzoates  Alkalins.'  Gaz.  des 
Hop.,  1856. 

t  ?>Q}ivixi\^\!%  Jahresbericht,  Bd.  cvii.,  No.  7,  S.  21  ;  i860. 


404  MERCURY 


special  virtues,  which  are  well  known  and  extensively- 
utilized  in  the  treatment  of  other  diseases.  None  of  them 
are  specifics  for  gout,  but  in  varying  degrees  they  are  all 
beneficial. 

Mercury. — A  considerable  share  of  the  usefulness  of 
mercury  in  gout  is  due  to  its  stimulating  effect  on  the 
liver.  As  a  purgative,  the  relief  which  it  gives  to  the  symp- 
toms of  portal  congestion  has  rendered  it  deservedly 
popular  among  this  class  of  patients,  who  so  frequently 
labour  under  the  depressing  effects  of  hepatic  torpor.  Its 
mode  of  action  as  an  alterative  is  ill  understood.  It  is 
remarkable  that,  although  readily  absorbed  into  the  tissues, 
it  does  not  so  readily  leave  them;  and  it  has  been  found  in 
all  of  them,  and  with  special  abundance  in  the  liver.  The 
slowness  with  which  it  is  excreted  is  perhaps  connected 
with  its  tendency  to  combine  with  albumen.  Unlike 
some  other  metals,  such  as  lead,  arsenic,  and  antimony,  it 
does  not  set  up  any  recognisable  changes  in  the  viscera, 
nor  in  the  other  tissues  short  of  mercurialism.  Although 
the  mercurial  cachexia,  with  its  varied  results,  is  more 
rapidly  induced  in  the  subjects  of  renal  disease,  and 
the  general  symptoms  of  renal  disease  may  suffer  aggrava- 
tion from  a  mercurial  course,  the  kidney  itself  is  not 
directly  affected  in  its  structure,  as  it  is  in  lead  intoxica- 
tion. 

The  special  liability  to  renal  complication  in  gout,  and 
the  frequency  of  renal  disease,  suggest  the  greatest  caution 
in  the  administration  of  mercury ;  but  of  its  usefulness  in 
some  chronic  forms  of  the  affection  there  is  not  any  doubt. 
Its  diuretic  action  has  been  much  insisted  upon  of  late 
years ;  yet,  according  to  Mitchell  Bruce,  it  does  not 
render  the  total  excretions  more  abundant,  and  there 
is  no  positive  evidence  of  its  producing  an  increased 
metabolism. 


ARSENIC  AND  SULPHUR  405 

Arsenic,  easily  taken  up  into  the  tissues  and  easily 
excreted,  exercises  a  perceptible  effect  upon  their  meta- 
bolism, increasing  the  nitrogenous  waste  probabl}^  through 
an  indirect  stimulation  of  the  process  of  oxidation,  and 
inducing  a  conversion  of  their  albuminous  constituents 
into  fat.  This  undesirable  result  belongs  rather  to  the 
toxic  than  to  the  therapeutical  action  of  the  drug.  With 
small  doses,  and  with  a  systematic  alternation  of  the 
periods  of  administration  with  periods  of  rest  from  the 
use  of  the  drug,  its  beneficial  advantages  may  be  secured 
without  any  risk.  In  this  way  it  has  been  successfully 
prescribed  in  chronic  gout.  The  special  influence  exerted 
by  arsenic  upon  the  skin  and  upon  the  nervous  system, 
the  metal  being  abundantly  found  after  poisoning  in  the 
grey  matter  of  the  cord,  is  an  argument  for  its  administra- 
tion which  would  appeal  to  the  supporters  of  the  nervous 
theory  of  gout. 

Sulphur  is  one  of  our  most  useful  agents  in  gout  as  well 
as  in  chronic  rheumatism.  The  rationale  of  its  action  is 
not  thoroughly  understood.  Administered  as  an  alkaline 
sulphide  or  as  sulphuretted  hydrogen,  it  is  a  reducing 
agent,  and  overdoses  powerfully  depress  the  nerve-centres, 
producing  respiratory  and  cardiac  failure.  Sulphur  itself 
in  the  uncombined  state  may  partake  of  this  property. 
At  any  rate,  it  is  an  alterative  of  undoubted  value.  Its 
stimulating  effect  upon  the  skin,  including  its  diaphoretic 
action,  has  variously  been  regarded  as  as  indication  and 
as  a  contra-indication.  Some  forms  of  eczema  are  de- 
cidedly the  worse  for  its  use ;  nevertheless,  it  has  some- 
times been  prescribed  for  this  complaint.  Individuals  pro- 
bably differ  widely  in  their  toleration.  Similarly,  its  action 
upon  the  respiratory  membrane  needs  careful  watching. 
In  the  stage  of  hypersecretion  bronchial  catarrh  is  greatly 
benefited  by  sulphur,   but  when    the  excessive  flow  has 


4o6  IODINE  AND  THE  IODIDES 


been  checked,  its  continued  administration  may  become  a 
source  of  irritation. 

Much  of  the  efficacy  of  sulphur  in  these  various  direc- 
tions is  doubtless  due  to  its  purgative  action,  and  to  the 
relief  which  it  affords  to  portal  congestion  and  to  hepatic 
engorgement.  This  is  probably  the  secret  of  the  great 
success  of  the  treatment  of  gout  by  sulphur  waters. 

Iodine  and  the  iodides  are  of  decided  value  in  gout,  though 
we  are  at  a  loss  to  explain  the  mechanism  of  the  relief 
which  they  give.  Of  their  widespread  alterative  action, 
we  possess  varied  and  conclusive  evidence,  especially  in 
connection  with  the  lymphatic  organs  and  their  functions, 
and  with  the  cardio-vascular  system. 

Upon  the  blood  itself,  iodine  in  toxic  doses  exercises  a 
remarkable  action,  increasing  its  fluidity  and  dissolving 
some  of  the  red  corpuscles.  Advanced  kidney  disease, 
which  checks  its  elimination,  is  for  that  reason  a  decided 
contra-indication.  The  same  remark  applies  to  other  forms 
of  cachexia  and  to  ansemia. 

The  great  therapeutical  feature  of  iodine  is  the  ex- 
traordinary rapidity  with  which  it  travels  through  and 
permeates  the  system,  loosely  combining  with  available 
albumens,  and  more  firmly  with  certain  metals,  such  as 
lead  and  mercury,  and  speedily  passing  out  of  the  body 
with  the  urine,  with  various  glandular  secretions,  and 
partly  also  by  exhalation  from  the  respiratory  mucous 
membrane.  This  swift  transit,  which  stimulates  and 
accelerates  metabolism,  has  probably  much  to  do  with 
the  beneficial  effects  obtained  from  its  administration  in 
chronic  and  subacute  gout  and  in  goutiness. 

Iodine  differs  from  the  other  members  of  this  group  in 
not  perceptibly  influencing  the  liver  or  the  kidney ;  it  may 
therefore  be  credited  with  a  direct  action  on  some  of  the 
processes  of  metabolism. 


IRON,  THE   VEGETABLE  TONICS,  AND  GUAIACUM    407 

IRON,  THE  VEGETABLE  TONICS,  AND  GUAIACUM. 

Little  need  be  said  of  each  of  the  members  of  this 
group.  Their  use  is  famihar  to  everyone.  In  gout  it 
presents  no  risks  or  reservations  which  could  not  be 
pointed  out  in  a  very  few  words.  They  are  best  adapted 
to  the  sub-acute  and  chronic  stages. 

Guaiacum  deserves  special  mention  in  connection  with 
its  well-marked  efficacy  in  the  myalgic  and  some  of  the 
neuralgic  forms^  and  with  its  decided  usefulness  as  a  laxative 
and  gentle  hepatic,  cutaneous,  renal,  and  cardiac  stimulant 
in  all  cases  of  chronic  gout,  and  particularly  in  the  atonic 
cases.  It  has  been  warmly  advocated  by  Sir  A.  Garrod, 
and  largely  prescribed.  Guaiacic  acid  (CgHgOg),  which 
presents  some  analogy  with  benzoic  acid,  has  been  com- 
bined with  metals.  The  guaiacate  of  lithium,  administered 
in  2  to  5  grain  doses,  conveys  some  of  the  virtues  of  the 
drug  under  a  smaller  bulk ;  but  powdered  guaiacum  or 
the  ammoniated  tincture  are  more  reliable  agents. 

It  is  noteworthy,  as  bearing  upon  the  yet  undetermined 
mode  of  its  beneficial  action,  that  in  toxic  doses  guaiacum 
acts  as  a  gastro-intestinal. irritant,  and  produces  vomiting 
and  purging. 

Cinchona  and  its  alkaloids  are  of  the  greatest  use,  and 
are  hardly  subject  to  any  contra-indication  in  the  non- 
acute  stages.  Although  Dr.  Haig  has  shown  that,  in 
common  with  thein,  caffein,  and  other  nitrogenous  bases, 
and  with  the  acids  and  the  metals,  quinine  tends  to  drive 
uric  acid  into  the  tissues,  as  a  corrective  for  some  of  the 
more  depressing  evacuants  of  uric  acid  it  is  commonly 
prescribed  with  success,  especially  for  continued  use. 
Sydenham  was  of  opinion  that  '  of  simple  medicines 
Peruvian  bark  is  the  best.' 

Nux    vomica   and   strychnine   are    also    most    useful    as 


4o8  STRYCHNINE  AND  IRON 


general,  as  nervine,  and  as  stomachic  tonics.  In  their 
administration  regard  must  be  had  to  individual  nervous 
peculiarities,  and  to  the  degree  of  renal  efficiency.  Imper- 
fect renal  emunction  leaves  the  system  overcharged  with 
toxins,  some  of  which  are  convulsants,  and  to  these  we 
should  not  add  doses  of  a  medicinal  convulsant.  As  illus- 
trating this  point,  which  has  special  bearing  in  connection 
with  the  stagnation  of  waste  material  in  gout,  the  observa- 
tions of  my  friend  Dr.  T.  Brushfield,  of  Wimbledon, 
possess  much  value.  A  large  experience  has  convinced 
him  that  lying-in  women,  a  class  in  whom  catabolism  is 
proceeding  at  a  great  rate,  are  peculiarly  susceptible  to 
strychnine,  the  physiological  effects  being  produced  in 
them  by  quite  small  doses.  With  these  suggestions  the 
handling  of  this  important  remedy  may  be  left  to  the 
personal  judgment  of  the  physician. 

Iron  (and  the  same  remark  applies  to  manganese)  is  one 
of  the  most  difficult  remedies  to  administer  with  unerring 
success.  It  is  not  to  be  thought  of  whilst  a  recent  acute 
attack  is,  as  it  were,  within  sight.  As  in  the  acute  rheu- 
matic state,  so  in  the  gouty,  an  untimely  administration 
of  iron  will  almost  inevitably  determine  a  fresh  paroxysm. 
Dr.  Haig  explains  this  by  the  check  placed  upon  the 
elimination  of  uric  acid. 

On  the  other  hand,  in  many  of  the  subjects  of  chronic 
gout  and  of  goutiness,  a  mild  chalybeate  course  is  of 
signal  service.  The  best  mode  of  administration  is  that 
of  the  natural  ferruginous  waters  drunk  at  the  places 
where  they  flow.  Next  best  is  their  use  at  home  in  more 
moderate  quantities.  Lastly,  the  milder  preparations  of 
iron  may  be  prescribed  to  best  advantage  in  association 
with  a  gentle  alkaline  treatment,  with  sulphur,  or  simply 
in  their  organic  combinations  as  carbonates,  tartrates  or 
citrates.  The  management  of  the  liver  during  the  ferrugi- 
nous course  will  need  much  attention  and  judgment. 


SYDENHAM'S  ELECTUARY 


409 


SYDENHAM'S  ELECTUARY. 

Stomachics  are  the  most  valuable  of  our  tonics  in  gout. 
If  gout  is  a  disease  of  malnutrition,  and  if  the  latter  is 
aggravated  by  the  complication  of  dyspepsia,  stomachic 
measures  must  stand  at  the  head  of  all  remedial  medica- 
tion. This  M'as  thoroughly  appreciated  by  Sydenham, 
who,  indeed,  hardly  admitted  that  gout  could  be  influenced 
for  good  by  any  other  medicines.  '  For  my  own  part,  I 
prefer  an  electuary  of  the  complex  character  of  Venice 
treacle,  wherein  the  mutual  fermentation  of  the  simples 
heightens  their  virtue,  producing  a  Urtium  quid,  of  which 
the  virtue,  as  a  whole,  is  greater  than  the  virtue  of  the 
sum  of  its  elements.  For  the  sake  of  beginners,  I  will 
publish  the  form  which  I  most  use.     It  is  as  follows : 


Root  of  angelica, 
sweet-flag, 
masterwort, 
elecampane, 

Leaves  of  mugwort, 

lesser  centaury, 

white  horehound, 

germander, 

ground-pine, 

scordium, 

calamint, 

feverfew, 

meadow-saxifrage, 

St.  John's  wort, 

golden- rod, 


Leaves  of  wild-thyme, 
mint, 
sage, 
rue, 

Carduus  Benedictus, 
pennyroyal, 
southernwood, 
Flowers  of  chamomile, 
„  tansy, 

„  lily  of  the  valley, 

„  English  saffron, 

Seeds  of  pennycress, 

„         garden  scurvy-grass, 
„         caraways, 
Juniper  berries — aa  q.s. 


'  Collect  the  herbs,  flowers,  and  roots  at  the  season  most  favourable 
for  their  respective  virtues.  Dry,  and  keep  in  paper-bags  until  they 
fall  into  a  fine  powder.  Take  6  oz.  of  each.  Mix,  and  make  up  with 
a  sufficient  quantity  of  the  best  clarified  honey  and  Canary  wine. 
Make  into  an  electuary  of  the  due  consistence — secundum  artem. 
Two  drachms  to  be  taken  night  and  morning. 


4IO  SYDENHAM'S  ELECTUARY 


'  Or  (if  this  cannot  be  had)  use 


'R 

Conserve    of    garden    scurvy- 
grass,  5i  ss.  ; 

Roman  wormwood 


Wash  down  with   five  or  six 
spoonfuls  of : 

Sliced  horseradish,  Siii-  ; 
Garden  scurvy-grass,  xii.hand- 

fuls  ; 
Watercress  -v 
Candied  nutmeg  )        ^       '  1         Brooklime    f  _  _ 

Venice  treacle,  5iii. ;  !         Sage  \  ^^  *^-  ^^"^^^^^  ' 


aa  oi- 
Orange-peel, 

Candied  angelica  )  --  ■z 

f  3,3.  3SS»  ) 


Compound  powder  of  cuckoo- 
pint,  3ii-  ; 
Syrup  of  oranges,  q.s. 

Make  into  an  electuary.  Two 
drachms  to  be  taken  twice  a 
day. 


Mint  } 

The  peel  of  vi.  oranges  ; 
Bruised  nutmegs,  ii.  ; 
Brunswick  mum,  O.xii. 

Distil  in  a  common  still  until 
six  pints  are  given  ofif.' 


Who  knows  but  that  in  this  lavish  supply  of  the  bright 
ornaments  of  our  meadows  some  healing  virtues  may  yet  lie 
undiscovered  ?  The  lily  of  the  valley,  foxglove,  and  meadow- 
saffron  itself,  have  waited  long  for  a  recognition  of  their 
value.  The  majority  of  the  constituents  of  Sydenham's 
electuary  are  probably  inert,  but  their  number  and  variety 
are  symbolical  of  the  salutary  effects  of  the  fresh  vegetable 
principles,  and  of  a  varied  vegetarianism  in  diet,  in  the 
treatment  of  the  jaded  functions  of  the  gouty. 

We  have  now  discarded  all  doubtful  simples  in  favour 
of  a  few  vegetable  tonics  which  are  decidedly  efficacious, 
and  especially  of  gentian,  quassia,  calumba,  chiretta,  and 
cascarilla.  We  should  cling  to  their  use  in  chronic  gout 
by  the  side  of  that  of  the  more  potent  bitter  alkaloids. 
In  dealing  with  atonic  gouty  dyspepsia,  we  may  also 
wisely  adopt  Sydenham's  suggestion  in  respect  of  carmi- 
natives, and  combine  with  the  bitters  and  the  alkaline 
bicarbonates  cardamoms,  ginger,  capsicum,  and  others. 

The  famous  Portland  powder,  of  which  the  recipe  was 
purchased  and  published  by  the  second  Duke  of  Portland, 
is  stated  by  Garrod  to  have  consisted  of  equal  parts  of 


STOMACHIC  TONICS  411 

birthwort,  gentian,  ground-pine,  and  the  tops  and  leaves 
of  the  lesser  centaury ;  a  drachm  was  to  be  taken  fasting 
every  morning,  and  subsequently  smaller  doses,  but  the 
treatment  was  to  be  kept  up  for  twelve  months.  Sir 
A.  Garrod  gives  an  interesting  account  of  the  equally 
undeserved  praise  and  censure  lavished  on  this  probably 
harmless  preparation,  which  was  really  a  variation  on  the 
form  of  treatment  recommended  by  Sydenham,  and  long 
before  by  the  ancients. 


CHAPTER  XLIV. 

THE  INTERNAL  TREATMENT  OF  ACUTE 
GOUT. 

The  safety  of  the  patient,  the  safety  of  the  joint,  and  the 
rehef  of  the  local  pain — these  are,  in  the  order  of  their 
importance,  the  objects  of  our  treatment.  To  be  success- 
ful, it  must  have  regard  to  the  fact  that  the  acute  gouty 
arthritis  is  the  outcome  of  something  more  than  a  local 
irritation.  Merely  local  measures  could  not  cure  the  all- 
important  constitutional  cause,  though  the  joint  usually 
sets  up  the  more  urgent  claim.  According  to  the  modern 
view  of  the  march  of  events,  it  is  too  late  to  stop  the 
action  on  the  joint.  Nevertheless,  if  the  attack  should 
be  regarded  as  in  itself  curative,  it  would  afford  an  opening 
for  that  help  which  constitutional  treatment  may  give. 

Happily,  life  is  rarely  threatened,"^  except  by  the  occur- 
rence of  severe  complications  in  a  heavily  handicapped 
constitution.  Nevertheless,  the  patient's  desire  for  a 
treatment  both  prompt  and  active  may  lead  to  the  em- 
ployment of  remedies  necessitating  a  careful  watch  on 
the  constitutional  effects. 

Between  the  other  two  indications  there  is  no  opposi- 

*  Sydenham  had  a  poor  opinion  of  treatment  in  gout :  '  Nay,  more ; 
I  can  confidently  affirm  that  the  greater  part  of  those  who  are  sup- 
posed to  have  died  of  the  gout  have  died  of  the  medicine  rather  than 
the  disease.' 


THE  INITIAL  PURGATION  413 

tion ;  what  is  good  for  the  pain  is  usually  good  for  the 
joint. 

In  each  of  its  details  the  treatment  must  be  adapted 
to  the  individual  case,  with  due  regard  to  age,  to  the 
presence  or  absence  of  albumen  or  sugar  in  the  urine,  to 
constitutional  tendencies,  and  to  the  degree  of  severity  of 
the  attack.  The  following  remarks  apply  to  a  sthenic 
attack  occurring  in  an  adult  of  average  strength,  and 
with  sound  kidneys. 

The  paroxysm  almost  invariably  seizes  the  patient  in 
bed,  and  when  localized  in  the  foot,  keeps  him  there. 
The  obvious  indication  is  to  save,  by  recumbency,  waste 
of  energy,  and  a  dependent  position  of  the  limb.  Few 
patients  will  fail  to  understand  the  paramount  impor- 
tance of  the  horizontal  posture,  even  if  their  unrest  should 
drive  them  from  their  bed  to  the  couch. 

The  physician's  attention  is  first  directed  to  the  relief 
of  the  local  pain  by  the  means  to  be  presently  described, 
whilst  internal  remedies  are  being  provided. 

THE  INITIAL  PURGATION. 

The  patient,  just  prior  to  the  attack,  may  have  had 
constipation,  looseness,  or  well-regulated  bowels.  Where 
constipation  has  existed,  quick-acting  remedies  are  called 
for.  Two  or  three  grains  of  calomel  should  be  adminis- 
tered, and  followed  up  after  the  lapse  of  an  hour  by  a 
black  draught.  In  the  case  of  previous  regularity  we 
should  not  lose  sight  of  the  constipating  effect  of  severe 
local  pain ;  but  we  can  afford  to  employ  the  slower 
method  of  relief  by  means  of  a  pill,  supplemented  by  a 
dose  of  saline  the  next  morning.  Even  after  preceding 
looseness,  constipation  may  be  expected  to  supervene 
with  the  onset  of  the  fit  of  gout,  and  much  judgment 
will  be  needed  in  adapting  the  treatment  to  the  special 


414  THE  INITIAL  PURGATION 

requirement.  Fractional  doses  of  calomel  administered  in 
pill  will  best  fulfil  the  hepatic  indication  without  pro- 
voking an  undesirable  alvine  flux.  Half,  or  a  third,  or  a 
quarter  of  a  grain,  repeated  perhaps  after  an  interval  of 
two  hours,  will  meet  the  varying  necessities  of  cases ;  and 
if  no  spontaneous  action  should  ensue,  a  mild  saline  dose 
may  be  prescribed  in  due  course. 

Among  the  advantages  claimed  for  this  method,  not  the 
least  important  is  that  it  obviates  the  necessity  for  large 
initial  doses  of  colchicum.  The  full  benefit  of  the  drug 
may  now  be  secured  from  doses  which  will  not  expose 
the  patient  to  the  risk  of  undue  depression  or  intestinal 
irritation. 

The  Choice  of  a  Purgative. — Although  calomel  either 
in  very  small  or  in  larger  but  quickly  expelled  doses  is 
hardly  ever  resented,  caution  is  needed  in  its  administra- 
tion. Scudamore  prescribed  calomel  in  combination  with 
antimonial  powder  and  compound  extract  of  colocynth 
every  second  night,  or  even  every  night,  in  addition  to  a 
favourite  morning  draught  containing  extract  of  colchi- 
cum, with  magnesia  and  magnesium  sulphate.  Sir 
A.  Garrod,  in  view  of  the  occasional  intolerance  of  the 
gouty  for  mercury,  is  of  opinion  that  '  in  advanced  gout 
it  should  be  altogether  avoided.' 

As  a  substitute  for  calomel,  where  the  physician's  experi- 
ence or  that  of  the  patient  discountenances  its  use,  podo- 
phyllin  may  be  combined  with  the  colocynth  and  henbane 
pill  of  the  Pharmacopoeia. 

Colchicum  as  a  Purgative. — Those  who  have  regarded 
the  benefits  of  colchicum  as  mainly  due  to  its  purgative 
action  have  sometimes  pushed  its  uncombined  administra- 
tion till  the  action  was  fully  developed,  and  the  character- 
istic green  stools  were  obtained ;  more  often  some  other 
laxative   has   been   prescribed  with    it.     Sir  A.  Garrod's 


THE  INTERNAL  MEDICATION  415 

teaching  has  largely  discouraged  this  practice.  He  insists 
that  the  value  of  colchicum  does  not  reside  in  its  purgative 
properties — a  point  we  shall  presently  touch  upon  again. 

Nevertheless,  the  experience  of  some  practitioners  will 
cause  them  to  adhere  to  the  early  use  of  colchicum  as  an 
ingredient  in  an  aperient  draught,  following  in  this  the 
practice  of  Scudamore.  A  relatively  large  dose  can  in 
this  way  be  given,  and  whilst  safely  expelled,  may  yet  do 
some  service  in  other  ways.  Sir  Dyce  Duckworth  suggests 
that  half  a  drachm  added  to  a  black  draught  '  may  replace 
colchicum  during  the  day.' 

THE  INTERNAL  MEDICATION. 

Our  description  of  the  systematic  medicinal  treatment 
need  be  but  brief  after  the  remarks  which  have  been  made 
in  preceding  chapters  under  the  heading  of  the  various 
remedies.  Much  will  have  been  achieved  if  the  liver 
has  been  sufficiently  influenced  by  our  laxative  measures, 
particularly  if  they  should  have  included  a  full  dose  of 
colchicum.  The  action  of  the  latter  may  be  safely  kept 
up  by  adding  to  any  mixture  prescribed  doses  of  10  minims 
of  the  wine.  Unless  the  attack  be  unusually  severe,  the 
main  treatment  may  with  great  advantage  be  conducted 
on  the  milder  lines  of  refrigerants,  diaphoretics,  and 
antacids.  An  effervescing  combination  of  2  drachms  of 
the  solution  of  acetate  of  ammonium  with  15  grains  of 
citrate  of  potassium  and  some  flavouring  agent  may  be 
taken  every  four  hours.  Or  sodium  bicarbonate  and 
magnesium  citrate  may  be  prescribed  in  the  usual  doses. 

Opium*  is  contra-indicated  unless  it  be  administered  in 
the  form  of  Dover's  powder ;  but  it  will  be  better  to  order 

*  '  Nevertheless  it  will  not  be  amiss  to  take  a  little  laudanum  in  the 
evening  if  the  pain  be  above  bearing.  Otherwise  it  will  be  better 
omitted.'— Sydenham. 


4i6  THE  INTERNAL  MEDICATION 


for  the  night  a  draught  which  may  be  repeated  without 
inconvenience  if  the  pain  should  be  excessive.  For  this 
purpose  potassium  bromide,  tincture  of  hyoscyamus,  and 
spirits  of  chloroform  in  camphor  -  water,  is  a  useful 
prescription.  Antipyrin,  which  is  recommended  by 
Dr.  Burney  Yeo,  or  phenacetin,  may  also  be  given  in 
repeated  doses. 

In  contrast  with  this  bland  treatment,  we  may  refer  to 
some  more  active  methods. 

Colchictmi  in  relatively  large  and  repeated  doses  is  now 
seldom  required.  This  practice  has  its  disadvantages,  to 
which  we  need  not  again  refer. 

Sodium  salicylate  in  the  large  and  frequent  doses  which 
afford  quick  relief  to  acute  rheumatic  arthritis  is  strongly 
recommended  by  Dr.  Haig.  We  have  no  experience  of 
this  method.  We  have  already  dwelt  on  the  objections 
to  which  it  is  open.  Albuminuria  and  a  fortiori  kidney 
disease  are  absolute  contra-indications.  At  the  best,  the 
renal  function  is  under  suspicion,  and  we  feel  diffident  of 
any  medication  making  heavy  and  continuous  demands 
upon  its  excretory  activity. 

In  small  doses  sodium  salicylate  appears  to  be  well 
borne,  and  the  milder  attacks  are  often  successfully 
treated  in  this  way.  Before  its  adoption  the  urine  should 
be  tested  for  albumen,  and  any  symptoms  of  salicylism 
must  be  watched  for  during  its  administration. 

Large  doses  of  the  alkaline  salts  are  not  desirable  during 
the  acute  attack.  The  time  has  passed  for  their  solvent 
action,  which  Sir  W.  Roberts,  moreover,  has  shown  to  be 
problematical.  Whilst  no  benefit  can  accrue  from  their 
use,  their  depressing  effect  is  a  strong  objection. 

Tincture  of  iodine  is  highly  spoken  of  by  Dr.  Mortimer 
Granville,  who  prescribes  it  in  lo- minim  doses,  with 
chlorate  of  potassium  and  chloride  of  ammonium.     We 


THE  DIET  IN  ACUTE  GOUT  417 

believe  in  its  efficacy  in  chronic  gout,  and  in  various 
forms  of  goutiness,  but  have  not  employed  it  in  acute 
gout. 

Whatever  medicinal  agents  may  be  preferred,  a  most 
essential  part  of  treatment  is  the  free  administration  of 
fluids.  The  onset  of  diaphoresis  is  acknowledged  as  a 
comfort,  and  cannot  fail  to  allay  the  feeling  of  feverishness 
and  unrest. 

THE  DIET  IN  ACUTE  GOUT. 

At  the  onset  and  during  the  worst  stage  solids  are  not 
required,  neither  are  they  often  acceptable.  In  this  acute 
gout  resembles  acute  rheumatism  ;  in  neither  of  them  is 
there  much  appetite  so  long  as  the  pain  is  severe.  Yet  we 
do  not  so  often  find  in  gout  that  complete  anorexia  which 
lasts  for  at  least  two  or  three  days  in  acute  rheumatism. 
In  gout  the  appetite  is  often  not  absolutely  killed.  This 
must  be  borne  in  mind,  together  with  the  fact  that  the 
pain  is  peculiarly  severe  and  exhausting,  and  that  the 
hitherto  luxuriously-fed  stomach  may  feel  the  craving  for 
stimulation. 

Nevertheless,  in  the  acute  stage  of  sthenic  gout  nothing 
but  good  can  come  from  restricting  the  diet  to  fluids : 
milk,  variously  diluted  with  hot  water  or  effervescing  v/ater, 
koumiss  or  whey,  barley-water  or  gruel,  and  perhaps  some 
weak  tea.  The  next  day  chicken-broth  with  thin  toast 
will  be  a  welcome  addition  ;  and  in  favourable  cases  there 
is  no  reason  why,  after  twenty-four  hours  of  the  rigid  fluid 
diet,  light  puddings  rendered  tasty  with  spices,  and 
sweetened  with  saccharine,  should  not  be  allowed.  Light 
farinaceous  food  is,  however,  the  only  kind  suitable  to  this 
stage. 

The  return  to  a  solid  diet  should  be  gradual.  A  little 
boiled  fish,  and  a  sago  or  tapioca  pudding  with  dry  toast, 

27 


4i8  THE  DIET  IN  ACUTE  GOUT 

should  suffice  for  the  single  solid  meal,  which  should  be 
taken  in  the  middle  of  the  day.  An  egg  for  breakfast  and 
some  milk-pudding  for  supper  may  also  be  allowed.  These 
rigid  rules  can  only  be  relaxed  when  the  patient  is  equal 
to  a  little  exercise  in  the  room,  or  to  a  drive. 

The  question  as  to  alcohol  does  not  arise  in  the  ordinary 
case  of  acute  gout,  but  should  be  considered  in  asthenic 
cases. 


CHAPTER  XLV. 
THE  LOCAL  TREATMENT  OF  ACUTE  GOUT. 

THE  GENERAL  INDICATIONS. 

Simple  measures  of  nursing  are  of  distinct  value  in  pro- 
viding for  the  support  and  protection  of  the  hmb.  The 
patient's  severe  pain  and  restlessness,  and  our  inability  to 
subdue  them  immediately,  lend  importance  to  these  lesser 
indications. 

Position  and  Support. — On  general  principles  elevation 
of  the  limb  is  indicated,  although  the  relief  thus  obtained 
is  slight  compared  with  that  afforded  in  ordinary  inflam- 
mation. When,  as  in  most  cases,  the  foot  is  the  seat  of 
pain,  the  lower  limb  must  be  so  arranged  as  to  allow 
perfect  freedom  to  the  circulation,  both  at  the  bend  of 
the  knee  and  in  the  groin.  This  is  essential  for  the  relief 
of  local  congestion,  and  for  the  avoidance  of  any  pressure 
on  the  veins,  phlebitis  being  among  the  dangers  to  be 
guarded  against. 

The  unavoidable  restlessness  of  the  patient  also  demands 
a  certain  freedom  of  movement,  and  this  should  be  pro- 
vided for  ;  but  when  all  has  been  done,  it  will  be  found  that 
the  patient  will  seek  for  himself  the  attitude  of  greatest 
relief. 

The  limb  should  be  made  to  lie  as  softly  as  possible,  so 
long  as  it  is  sufficiently  supported.  Water  and  air 
cushions    are   somewhat  disappointing   in   their  want  of 


420  THE  GENERAL  INDICATIONS 

steadiness,  but  they  obviate  much  pain  from  shaking  or 
vibration.  Any  rough  contact  is  also  to  be  guarded 
against,  and  the  weight  of  the  bed-clothes  taken  off  by  a 
large  cradle  placed  over  the  limb. 

Simple  applications,  such  as  cotton  wool  or  flannel,  are 
always  grateful  and  safe.  Their  virtue  is  their  warmth 
and  lightness,  and  the  exclusion  of  all  draughts  of  air. 
Many  are  intolerant  of  any  weight,  and  prefer  for  this 
reason  fomentations  to  poultices ;  these,  however,  are 
often  of  use,  and  were  praised  by  Sydenham  :  '  A  poultice 
made  with  white  bread,  saffron,  and  a  small  quantity  of 
oil  of  roses,  has  done  me  more  good  than  aught  else. 
Nevertheless,  at  the  onset  of  a  fit  it  did  nothing.  Hence, 
if  the  pain  be  very  violent,  the  patient  will  do  better  by 
lying  in  bed  until  it  have  somewhat  remitted  than  by 
using  anodynes.' 

Warmth  and  Moisture. — Both  are  beneficial.  In  apply- 
ing warmth  we  never  do  harm,  but  assist  nature  in  pro- 
moting cutaneous  action,  and  the  patient's  feelings  bear 
witness  to  this.  Our  policy  is  not  to  subdue  abruptly  the 
inflammatory  swelHng,  but  rather  to  relieve  the  tension 
of  the  tissues,  and  for  this  end  moisture  is  also  indicated. 
The  most  effectual  means  is  the  cautious  employment  of 
steam,  and  if  simpler  methods  do  not  give  relief,  this  may 
be  resorted  to,  not,  however,  without  the  physician's 
supervision. 

Simple  Method  of  Steaming  the  Limb. — A  local  steam 
bath  may  be  improvised  in  a  few  minutes  with  the  aid  of 
the  following  simple  requisites :  an  ordinary  kettle,  to 
which  is  attached  a  good  length  of  gas-tubing ;  an  ample 
piece  of  india-rubber  sheeting  (a  mackintosh  garment  ma}' 
be  turned  to  account) ;  a  common  packing-box  of  suitable 
size  converted  into  a  cradle  by  knocking  the  two  opposite 
sides  out  of  it ;  lastly,  a  couple  of  garters  or  india-rubber 


THE  GENERAL  INDICATIONS  421 

bands  of  proper  size.  The  limb  is  to  be  carefully  wrapped 
in  flannel  from  the  knee  to  the  ankle,  and  a  loose  layer  of 
cotton-wool  placed  over  the  foot  and  completely  covered 
with  flannel.  The  cradle  having  been  fixed  over  the 
mackintosh  and  pillow  which  support  the  foot,  a  second 
piece  of  waterproof  sheeting  is  spread  over  the  whole,  well 
tucked  in  under  the  sides  of  the  pillow,  and  fixed  by  the 
garter  below  the  knee.  Before  doing  this,  the  end  of  the 
india-rubber  tube,  well  protected  from  immediate  contact 
with  the  skin  by  a  thick  layer  of  cotton-wool,  is  to  be 
securely  fixed  to  the  under  surface  of  the  cradle  at  a 
distance  from  the  foot.  The  foot  end  of  the  apparatus, 
left  open  at  the  beginning  of  steaming,  is  gradually  closed. 
This  is  best  done  at  the  patient's  own  judgment,  by  draw- 
ing the  waterproof  partly  or  entirely  over  the  opening. 
The  duration  of  the  steam  bath  need  not  exceed  ten 
minutes  in  most  cases. 

THE  LOCAL  MEASURES  OF  TREATMENT. 

Local  Depletion. — The  application  of  leeches,  a  sovereign 
remedy  for  many  painful  inflammatory  affections,  has  been 
found  comparatively  useless  in  acute  gouty  arthritis.  In 
this  country  Cullen  seems  to  have  been  its  last  advocate. 
Scudamore,  although  still  a  partisan  of  the  use  of  the 
lancet,  and  Todd,  who  was  opposed  to  it,  both  agreed  in 
deprecating  local  leeching.  Since  Sir  A.  Garrod's  un- 
equivocal disapproval  of  the  method,  it  has  probably  rarely 
been  practised.  The  objections  which  have  been  raised 
against  it  are  chiefl.y  based  upon  the  disappointing  results 
obtained,  and  upon  the  risk  of  superadding  an  erysipela- 
tous inflammation  to  the  gouty.  Moreover,  in  a  few 
reported  cases  an  aggravation  of  the  local  symptoms, 
permanent  weakness  (Todd),  early  ankylosis  (Garrod),  or 
a  metastasis  of  the  inflammation,  have  been  noted. 


422  THE  LOCAL  MEASURES  OF  TREATMENT 

Local  Blistering. — Some  of  the  objections  urged  against 
the  use  of  leeches  are  also  applicable  to  the  practice  of 
blistering,  which,  however,  has  had  eminent  supporters. 
Sir  A.  Garrod  considers  blisters  unnecessary  in  the  early 
attacks,  and  restricts  their  use  to  asthenic  cases  with  a 
tendency  to  effusion.  Sir  Dyce  Duckworth  adheres  to 
the  same  view.  Bearing  in  mind  the  possibility  of  com- 
plications, and  the  widely  different  manner  in  which  even 
healthy  skin  reacts  to  the  same  blistering  agent  in  different 
individuals,  the  wisest  course  is  to  avoid  any  risk,  and  to 
select  some  other  form  of  local  treatment. 

Topical  Applications.  —  The  list  of  local  applications 
vaunted  or  approved  in  practice  is  a  very  long  one.  They 
may  be  classified  under  the  headings  of  anodyne,  stimu- 
lant, alkaline,  and  astringent  applications.  Members  of 
two  or  three  of  these  groups  may  sometimes  be  combined 
with  advantage.  Colchicum,  so  efficient  internally,  has  also 
been  applied  to  the  surface,  but  without  definite  results. 

Astringents. — Of  the  use  of  astringents  in  local  treatment 
the  same  may  be  said  in  principle  as  of  the  use  of  cold. 
The  lessening  of  the  local  vascular  fulness  by  any  violent 
measures  is  not  in  agreement  with  our  view  of  the  require- 
ments, and  is  not  devoid  of  danger.  Nevertheless,  when 
coupled  with  the  application  of  warmth  and  of  seda- 
tives, such  astringents  as  a  weak  solution  of  acetate  of 
lead  or  a  warm  infusion  of  astringent  leaves  ma}^  give 
considerable  relief.  In  usual  practice  warm  Goulard  and 
opium  covered  with  oil-silk  is  found  to  be  satisfactory. 

Anodynes. — ^The  preparations  of  opium  stand  at  the  head 
of  the  list.  Lotions  containing  laudanum  are  commonly 
resorted  to,  or  laudanum  may  be  sprinkled  on  fomenta- 
tions or  on  poultices  when  applied.  Morphia  can  also  be 
used  as  an  ointment  or  in  solution. 

The  preparations  of  belladonna  are  also  highly  recom- 


THE  LOCAL  MEASURES  OF  TREATMENT  423 

mended  and  extensively  used  by  some.  The  glycerine  of 
belladonna  is  a  convenient  form  ;  or  a  bland  ointment,  such 
as  the  Pharmacopoeial  atropine  ointment,  may  be  pre- 
ferred. Sir  Dyce  Duckworth  speaks  well  of  the  combina- 
tion of  atropine  and  morphine  in  solution  of  oleic  acid, 
which  should  be  painted  over  the  painful  joint ;  he  also 
refers  to  the  local  use  of  flexile  collodium  and  of  French 
chalk,  but  deprecates  any  agent  likely  to  choke  the  sweat- 
ducts. 

Cocaine  has  been  recommended  according  to  various 
formulae  as  an  ointment  or  as  a  liniment.  Camphor- 
chloral,  ichthyol,  and  menthol  have  also  been  used. 

Stimulant  Applications. — The  handiest  of  all  applications 
are  the  warm  spirituous  lotions  patronized  by  many  gouty 
patients.  The  spirit  and  water  is  applied  on  flannel  or 
lint,  and  covered  with  oil-silk.  Such  apparently  unpro- 
mising remedies  as  iodine  painted  on  the  joint,  or  nitrate 
of  silver  applied  or  gently  rubbed  over  the  inflamed  sur- 
face, have  been  resorted  to  by  patients  who  have  experi- 
enced benefit  from  them.  They  should  rather  be  left  to 
individual  selection  on  the  part  of  the  latter  than  recom- 
mended by  the  physician  in  the  absence  of  any  previous 
knowledge  of  the  effects  personal  to  the  patient.  To  the 
same  class  belong  such  remedies  as  the  oil  of  peppermint, 
or  the  lotion  of  menthol  mentioned  by  Duckworth. 

Alkaline  Applications. — These  are  of  undoubted  value  in 
many  cases.  Weak  solutions  of  the  carbonate  or  of  the 
bicarbonate  of  sodium,  in  the  proportion  of  an  ounce  of 
the  salt  to  a  pint  of  water,  are  popular  remedies  ;  they 
should  be  applied  warm.  The  relief  obtained  from  them 
is  greatly  enhanced  by  the  addition  of  laudanum,  and  is 
accelerated  by  a  preliminary  course  of  vapour  carefully 
regulated  as  regards  temperature,  and  suitably  adjusted  so 
as  to  take  effect  on  the  inflamed  surface  without  causing 


424  THE  LOCAL  MEASURES  OF  TREATMENT 

irritation.  Or  the  joint  may  be  packed  with  a  warm 
alkahne  and  opium  lotion  (|  oz.  of  crystals  of  carbonate 
of  sodium,  2  drachms  of  laudanum,  10  oz.  of  water.  Mix 
with  an  equal  quantity  of  hot  water;  then  pour  some  of 
the  hot  lotion  over  the  part,  which  is  packed  in  cotton- 
wool covered  with  oil-silk,  and  raised. — Burney  Yeo). 

The  purpose  of  this  form  of  treatment  is  different  from 
that  with  which  it  is  applied  to  the  concretions  of  chronic 
gout.  The  inflamed  skin  is  not  in  a  condition  to  absorb 
appreciable  amounts  of  any  substance,  even  the  most 
diffusible.  On  the  contrary,  our  endeavour  is  rather  to 
promote  excretion,  and  in  this  respect  warm  moisture  and 
alkalies  are  superior  to  all  other  agents,  especially  if,  con- 
trary to  the  rule,  the  sweat-glands  should  remain  inert,  in 
spite  of  the  previous  application  of  cotton-wool.  Marked 
relief  is  given  to  the  painful  tension  of  the  fibrous  stroma, 
the  pressure  on  the  cutaneous  lymphatics  is  lessened,  and 
the  natural  flow  within  them,  from  which  relief  is  ultimately 
to  be  sought,  tends  to  be  restored.  At  the  same  time, 
lateral  pressure  is  taken  off  the  painful  nerve-endings,  and 
their  own  structural  elements  are  probably  relaxed.  It 
need  hardly  be  pointed  out  that  the  wall-tension  of  arteries 
and  veins  is  lessened,  and  circulation  within  them  con- 
siderably favoured. 

Ice  and  Cold. — The  application  of  cold  should  be  men- 
tioned chiefly  to  warn  against  it.  In  the  agony  of  their 
pain  patients  are  occasionally  driven  to  try  this  method. 
Hippocrates  and  Galen  mention  cold  affusion  as  a  means 
of  relief ;  and,  according  to  Heberden,*  Sydenham  was  in 
the  habit  of  plunging  his  painful  limb  into  cold  water. 
Rothef  has  within  recent  years  revived  the   practice  of 

*  Quoted  by  Rendu. 

t  '  Behandlung  der  Gicht  mit  Kalten  Douchen  :'  Memorabilien, 
Heft  2,  1877  (quoted  by  Rendu). 


THE  LOCAL  MEASURES  OF  TREATMENT  425 

systematic  cold  affusions  and  applications,  and  states  that 
he  has  thereby  relieved  the  pain  and  shortened  the  dura- 
tion of  the  attacks. 

In  spite  of  this  advocacy  the  practice  is  one  to  be 
strictly  avoided.  The  dangers  incidental  to  it  have  been 
sufficiently  dwelt  upon.  Cold  is  invariably  repugnant  to 
the  local  feelings  of  the  patient,  and  we  have  it  on  Garrod's 
authority  that,  when  the  sudden  revulsion  of  the  cold 
douche  succeeds  in  allaying  the  inflammation  or  in  mitiga- 
ting the  pain,  this  relief  is  but  temporary,  and  the  acute 
attack  is  not  materially  shortened. 

An  exception  must  be  made  in  favour  of  the  modified 
method  of  treatment  by  ice,  as  suggested  by  Sir  W.  Wade. 
In  the  belief  that  the  pain  is  mainly  localized  in  the  nerves, 
and  due  to  their  inflammation,  he  suggests  the  application 
of  ice  along  the  lines  followed  by  them,  which  are  also 
those  of  the  acute  tenderness.  The  objections  mentioned 
above  do  not  apply  here,  since  the  greater  part  of  the  con- 
gested limb  is  not  submitted  to  refrigeration.  Ice  in  this 
case  is  used  as  a  strictly  local  anodyne  or  anaesthetic, 
whilst  it  may  help  in  subduing  any  existing  neuritis  or 
congestion. 

The  simplest  method,  is  to  select  a  wedge-shaped  piece 
of  ice,  the  sharp  edge  of  which  may  be  made  smooth  by 
dipping  into  hot  water,  and,  holding  it  in  a  thick  fold 
of  blotting-paper  or  flannel,  to  rub  it  lightly  along  the 
course  of  the  nerve,  much  in  the  same  way  as  a  tailor  uses 
his  chalk.  The  application  often  gives  great  relief  to  the 
pain,  and  is  not  accompanied  with  any  of  that  shock 
which,  above  all  things,  is  to  be  avoided  in  gout. 


CHAPTER  XLVI. 

THE  TREATMENT  OF  CHRONIC  ARTICULAR 

GOUT. 

THE  CHIEF  INDICATIONS. 

This  chapter  will  include  a  consideration  of  those  cases  in 
which  subacute  attacks  of  genuine  gouty  arthritis  are  of 
frequent  occurrence  and  easily  provoked,  though  the  joints 
may  not  present  permanent  changes,  and  those  in  which 
permanent  deformity  has  resulted,  whilst  the  gouty 
tendency  remains  in  active  progress.  Gouty  cachexia, 
which  also  belongs  to  the  '  chronic '  group,  calls  for  a 
treatment  differing  so  widely  from  that  to  be  described, 
that  it  should  be  considered  separately.  The  treatment 
of  goutiness  and  of  its  various  visceral  manifestations  will 
claim  separate  chapters. 

The  cases  in  question  constitute  the  majority  of  those 
which  seek  treatment  for  the  relief  of  gout ;  and  the  greater 
part  of  the  therapeutics  of  gout  has  reference  to  them. 

In  tophaceous  gout  and  in  crippling  gouty  arthritis  an 
additional  indication  arises,  that  of  the  local  treatment  of 
the  joint,  for  which  in  the  remaining  cases  there  is  only  an 
occasional  need.  The  constitidional  treatment  is  an  indica- 
tion common  to  the  whole  group,  but  which  in  its  details 
varies  with  each  set  of  cases.  Thus,  in  all  cases  of  con- 
firmed gout  the  main  indications  have  reference  to  the 
constitutional  rather  than   to  the  local  trouble.     If  the 


THE  CHIEF  INDICATIONS  427 

process  of  nutrition  can  be  restored  to  a  healthy  state,  all 
the  phenomena  of  gout,  including  the  uratic  dyscrasia, 
will  be  under  control.  The  means  to  this  end,  fore- 
shadowed in  the  chapters  on  the  pathological  and  clinical 
aspects  of  gout,  are  : 

1.  An  improved  excreting  activity  of  the  bowel,  skin, 
and  kidney. 

2.  A  more  active  metabolism,  for  which  the  glandular 
organs,  and  particularly  the  liver,  should  be  appealed  to  by 
medicines,  and  the  muscular  system  by  exercise  and  oxygen. 

3.  An  improved  digestion  and  assimilation,  to  be 
secured  by  diet,  by  hygiene,  and  by  tonic  remedies. 

These  broad  outlines  include  in  detail  the  use  of  the 
following  agents  :  purgatives  and  laxatives,  diaphoretics, 
diuretics,  glandular  stimulants,  hepatic  stimulants,  chola- 
gogues,  alteratives  (especially  those  capable  of  accelerating 
tissue  change),  and  lastly,  in  addition  to  hygiene  and  diet, 
the  important  group  of  gastric  and  nervine  tonics. 

At  the  same  time,  we  should  not  lose  sight  of  the 
articular  indication  in  connection  with  internal  treatment, 
the  cherished  aim  of  which  has  been,  for  the  last  forty 
years,  to  dissolve  the  deposits  of  the  biurate  by  chemical 
remedies.  This  therapeutic  intention,  which  has  never 
been  perfectly  fulfilled,  is  represented  in  our  list  of 
medicines  by  the  alkaline  group,  and  by  some  other 
alleged  solvents  of  uric  acid. 

GENERAL  MANAGEMENT  OF  CHRONIC  GOUT. 
Chronic  gout  is  not,  like  the  acute  attack,  self-curative. 
So  long  as  the  circumstances  which  led  to  it  prevail,  it 
tends  to  grow  worse.  Its  continuance  is  a  proof  that  the 
sufferers  have  neither  known  how  to  ward  off  its  approach 
nor  how  to  check  its  progress.  They  are  eminently  in 
need  of  advice. 


428      GENERAL  MANAGEMENT  OF  CHRONIC  GOUT 


Yet  in  the  earlier  stages,  if  they  could  act  fully  up  to 
our  present  knowledge  of  treatment,  gouty  patients  would 
need  little  medicine  for  their  cure.  They  might  be  their 
own  physicians  if  they  could  carry  out  with  perfect  fidelity 
the  great  rational  indications.  For  this  attainment  time 
and  patience  are  necessary.  As  stated  by  Sydenham  : 
'  Be  our  digestive^  remedies  what  they  may  (medicines, 
diet,  exercise),  they  must  not  be  taken  by-the-by,  but 
must  be  steadily  and  diligently  adhered  to.  In  gout,  as 
in  other  chronic  diseases,  the  cause  is  a  change  and  new 
nature  of  the  system.  Now,  no  sensible  man  can  believe 
that  light  and  momentary  change  can  remedy  this.  The 
system  must  be  transformed.  The  man  must  be  made 
anew.' 

The  physiological  preventives  and  the  physiological  cures 
for  gout  are  :  a  sufficiently  warm  climate,  a  vegetarian 
diet,  and  a  perfect  hygiene.  Each  of  these  alone  would 
avail  much,  but  success  can  only  be  assured  by  their 
combination. 

The  great  majority  of  our  patients  are  unable  to  carry 
out  any  of  these  methods  of  self-cure.  It  is  for  us  to 
devise  for  them  a  modified  treatment,  in  which  medica- 
tion seeks  to  make  up  for  that  which  is  unattainable  by 
simpler  means. 

Our  management  should  include  as  much  of  these  main 
indications  as  each  case  can  afford.  The  climatic  advantage 
may  be  partly  secured  by  residence,  at  least  for  part  of 

*  Sydenham  explains  thus  what  he  means  to  be  understood  by  a 
'digestive':  '  Whatever  helps  Nature  in  the  discharge  of  her  functions, 
either  by  comforting  the  stomach,  ...  or  by  strengthening  the  blood 
to  the  due  assimilation  of  the  chyle  brought  to  it,  or  by  restoring  the 
solid  parts  in  such  a  manner  as  to  fit  them  for  the  conversion  of  the 
juices  destined  for  their  growth  and  increase  into  their  own  proper 
substance,  .  .  .  whether  medicine,  diet,  exercise,  or  change  in  the 
non-naturals,  is  a  digestive.' 


GENERAL  MANAGEMENT  OF  CHRONIC  GOUT     429 

the  year,  at  some  of  our  warmer  health  resorts.  Of  these 
there  is  a  choice.  The  Isle  of  Wight,  Ilfracombe,  Torquay, 
Southsea,  St.  Leonards,  Worthing,  and  Brighton,  are 
among  the  best  known. 

For  those  who  can  travel,  the  winter  spent  in  Egypt 
or  the  Riviera,  in  Morocco  or  Algeria,  in  Spain  or  Italy, 
or  the  summer  spent  in  Switzerland,  will  fulfil  the  require- 
ment. Irrespective  of  the  influence  of  climate,  much  good 
accrues  from  the  renovating  effect  of  varied  scenery  and 
surroundings,  of  novel  impressions,  and  of  the  unforeseen 
which  is  more  frequently  happening  than  in  the  monotony 
of  home-life.  All  these  act  as  stimulants  to  the  nervous 
system,  and  react  favourably  on  the  functions. 

In  itself  the  interruption  of  the  routine  of  home,  even 
at  the  cost  of  some  pet  comforts,  is  most  beneficial. 
A  winter  tour  to  Northern  India,  to  New  Zealand,  to  the 
Southern  States,  especially  Southern  California,  or  Mexico, 
or  to  the  West  Indies,  is  much  to  be  recommended.  In 
America  and  in  New  Zealand  a  valuable  course  of  thermal 
waters  can  be  combined  with  the  tour. 

Whilst  discussing  the  question  of  travel,  we  may  briefly 
refer  to  that  of  balneology.  A  yearly  visit  to  some 
mineral  spring  forms  part  of  the  programme  of  treatment, 
and  whenever  manageable  should  be  carried  out.  We 
shall  enter  into  further  details  in  the  chapter  on  medicinal 
springs. 

The  dietetic  indication  of  vegetarianism  is  in  the  vast 
majority  of  instances  a  dead  letter.  Fortunate^,  very 
good  results  can  also  be  obtained  on  a  mixed  diet ;  but 
on  this  plan  the  patient  is  much  less  protected,  and  more 
open  to  the  temptations  and  risks  from  which  a  sterner 
rule  would  have  freed  him.  Selection  as  to  quality  and 
quantity  becomes  a  complicated  matter,  and  the  moral 
check  of  a  dietetic  prescription   has  to  be  resorted  to. 


430  GENERAL  MANAGEMENT  OF  CHRONIC  GOUT 

The  subject  of  diet  will  be  fully  dealt  with  further  on, 
and  with  it  that  of  alcohol,  an  important  detail  in  our 
general  management  of  chronic  gout. 

The  hygienic  indication  in  its  most  complete  form,  which 
will  be  described  in  a  special  chapter,  can  seldom  be 
carried  out.  Muscular  exercise  is  its  chief  essential,  but 
mental  exercise  should  not  be  excluded.  In  opposition 
to  a  prevailing  view,  Cantani  recommended  vigorous 
mental  activity.  It  should  never  be  carried  to  the  point 
of  exhaustion,  nor  take  the  place  of  the  needful  muscular 
exercise. 

The  physician's  advice  will  be  needed  to  apportion 
in  each  case  the  suitable  amount  of  exertion,  and  to 
regulate  all  matters  of  hygiene,  and  particularly  those 
relating  to  an  open-air  life. 

Unfortunately,  the  advanced  stage  of  the  affection  or 
unavoidable  circumstances  too  often  stand  in  the  way, 
and  chief  reliance  must  be  placed  on  medication  and 
careful  dieting. 

MEDICINAL  TREATMENT.— THE  LAXATIVE  AND 
SALINE  TREATMENT. 

So  long  as  a  mild  laxative  treatment  can  be  kept  up 
without  debilitating  the  subject,  we  may  hope  to  keep  the 
morbid  tendency  in  check.  Our  choice  of  remedies  is 
large.  We  may  divide  them  into  three  groups :  the 
simple  aperients,  the  hepatic  and  glandular  stimulant 
aperients,  and  the  muscular  stimulant  aperients. 

The  simple  aperients  are  represented  by  ordinary  salines 
devoid  of  any  special  hepatic  function,  such  as  the 
citrates  of  potash,  soda,  and  magnesia,  and  the  effer- 
vescing citrates  and  tartrates  so  largely  used  by  the 
public  under  various  names. 

The  muscular  stimulant  laxatives  have  two  important 


THE  LAXATIVE  AND  SALINE  TREATMENT        431 

representatives  in  cascara  and  in  guaiacum.  The  latter 
is  particularly  useful,  and  has  been  largely  prescribed  by 
Garrod.  It  has  the  advantage,  in  addition  to  its  purga- 
tive action,  of  definitely  relieving  muscular  and  other 
pains  in  gout.     The  use  of  cascara  is  now  well  known. 

The  list  of  hepatic  stimulant  laxatives  is  a  long  one. 
Their  vegetable  representatives  are  colchicum,  colocynth, 
podophyllum,  rhubarb,  aloes,  and  euonymin,  which  may 
be  with  advantage  combined  with  hyoscyamus.  The 
mineral  group  contains  sulphur,  a  most  useful  and  safe 
remedy  for  a  continuance,  most  convenient  in  the  form  of 
Garrod's  compound  sulphur  tablets,  and  rendered  com- 
paratively palatable  in  the  compound  liquorice  powder ; 
the  mercurial  preparations  as  occasional  correctives  ;  and 
the  stimulating  salines,  and  particularly  the  combination 
provided  by  nature  in  the  Sprudel  spring  at  Carlsbad, 
which  may  be  recommended  for  more  or  less  habitual  or 
for  recurrent  use. 

We  shall  refer  under  a  different  heading  to  the  laxative 
and  purgative  plan  temporarily  adopted  at  mineral 
stations. 

The  simple  saline  treatment  advocated  by  Garrod  often 
suffices  to  regulate  the  hepatic  and  intestinal  function, 
and  it  will  be  well  if  purgatives  can  be  put  aside  for 
occasional  use  only. 

Magnesia  and  its  carbonate  were  praised  by  Scudamore, 
and  are  of  undoubted  use  as  mild  antacids.  To  the 
virtues  of  the  sodium  bicarbonate  we  shall  revert  pre- 
sently. Lithia  and  its  salts,  and,  above  all,  bicarbonate 
of  potash,  have  been  largely  prescribed,  and  the  judicious 
and  temporary  use  of  the  latter  has  not  met  with  any 
serious  objection,  though  we  cannot  speak  favourably  of 
its  continued  administration  in  all  cases. 


432         DIURETIC  AND  DIAPHORETIC  TREATMENT 


THE  DIURETIC  AND  DIAPHORETIC  TREATMENT. 

Diaphoresis  as  obtained  by  muscular  exercise  will  be 
appropriately  considered  under  the  heading  of  hygiene. 
The  diaphoretic  agents  suited  to  chronic  gout  are  in  great 
part  identical  with,  and  partly  also  complementary  to,  the 
diuretic  measures.  The  warm  bath  which  predisposes  to 
sweating,  and  the  hot-air  and  vapour  bath  which  induce 
it,  are  direct  instalments  of  renal  treatment,  through  the 
relief  which  they  afford  to  the  function  of  the  kidney. 
The  hot-air  bath  may  be,  when  it  is  not  contra-indicated, 
of  signal  service  in  albuminuria  and  kidney  disease  de- 
pendent upon  gout. 

The  treatment  of  the  kidney  in  chronic  gout  has  a  double 
aspect.  The  careful  avoidance  of  irritating  beverages  and 
food,  and  the  free  use  of  diluents,  are,  together  with  free- 
dom of  the  cutaneous  and  intestinal  functions,  the  chief 
sources  of  relief  from  overpressure  in  the  renal  depart- 
ment. Diuresis  is  promoted  by  the  salts  of  potassium 
and  of  lithium,  now  largely  used ;  their  administration  in 
the  dilutions  recommended  by  Garrod  adds  much  to  the 
effect. 

A  safe  and  effectual  diuretic  is  pure  water  taken  in 
sufficient  quantity.  Special  advantages  belong  to  the  use 
of  hot  water  (a  tumblerful  on  waking,  at  bedtime,  and  an 
hour  before  the  mid-day  meal),  which  stimulates  the  skin 
and  the  alimentary  mucous  membrane,  as  well  as  the 
kidney. 

THE  ALKALINE  TREATMENT. 

The  method  which  endeavours  to  ensure  the  solubility 
of  the  excess  of  uric  acid  present  in  the  blood  in  chronic 
gout,  and  to  dissolve  the  biurate  deposited  in  the  joints  and 
tophi,  took  its  origin  in  chemical  observations  from  which 


THE  A  LKA  LINE  TREA  TMENT 


433 


inferences  were  drawn  far  in  excess,  as  Sir  W.  Roberts 
has  shown  by  further  chemical  research,  of  the  actual 
facts.  Are  we  to  conclude  at  Sir  W.  Roberts'  suggestion 
that  the  treatment  in  question  is  altogether  useless,  and 
that  the  persistence  of  tophi  and  the  recurrence  of  gouty 
seizures  in  spite  of  alkalies  administered  continuously  in 
doses  sufficient  to  keep  the  urine  alkaline  are  arguments 
against  the  further  use  of  alkaline  remedies  ?  A  single  ad- 
verse observation  of  this  kind  suffices  to  raise  the  strongest 
doubt  as  to  the  solvent  virtue  once  attributed  to  them. 

Nevertheless,  if  we  were  to  forget  the  existence  of  uric 
acid,  we  might  yet  find  in  their  general  properties,  which 
have  been  already  described  {cf.  p.  369),  ample  justification 
for  their  employment.  Besides  uric  acid,  we  observe  in 
gout  a  general  acidity  which  needs  to  be  controlled, 
a  retention  of  waste  products  which  need  elimination, 
a  slowness  of  metabolism  which  requires  stimulation. 
Alkalies,  and  specially  potassium  bicarbonate,  are  of 
value  as  local  and  general  antacids,  as  diuretics,  and  as 
alteratives,  and  their  moderate  doses  are  decidedly 
beneficial. 

In  giving  up  the  hope  of  dissolving  the  biurate,  we  need 
not  sacrifice  these  advantages,  but  we  are  freed  from  the 
chief  excuse  for  a  continuous  alkaline  treatment,  to  which 
there  are  valid  objections.  We  are  indebted  to  Sir  W. 
Roberts  for  repeating  with  renewed  force  Sir  A.  Garrod's 
original  recommendation  not  to  alkalize  the  subjects  of 
chronic  gout  to  the  extent  of  keeping  the  urine  alkaline. 
The  depression  which  this  induces  is  detrimental,  and  the 
same  remark  applies  in  many  cases  to  the  habitual  use  of 
potash  and  lithia  water.  These  waters  are  too  often 
regarded  as  mere  articles  of  diet.  They  should  be  pre- 
scribed by  the  physician,  not  by  the  patient. 

Sodium  bicarbonate,  for  reasons  which  we  need  not  re- 

28 


434  THE  ALKALINE  TREATMENT 

peat  {cf.  p.  379),  is  not  usually  resorted  to  for  the  purpose 
of  rendering  the  urine  alkaline.  Its  wide  range  of  useful- 
ness in  practical  therapeutics  as  an  antacid  and  as  an 
hepatic  stimulant  would  seem  to  point  to  its  special  value 
in  gout,  and  we  could  ill  afford  to  spare  it  unless  it  were 
definitely  shown  to  be  harmful.  That  it  promotes  the 
precipitation  of  the  biurate  is  the  inference  derived  from 
Sir  W.  Roberts'  experiments,  and  a  suspicion  to  the  same 
effect  was  long  ago  expressed  by  Sir  A.  Garrod.  We 
think  that  this  objection  is  partly  theoretical,  and  should 
not  deprive  us  of  the  legitimate  use  of  the  remedy.  In 
chronic  gout  it  has  been  and  is  largely  used,  not  only  on 
the  Continent,  but  in  this  country.  Some  patients  who 
have  experienced  its  benefits  take  it  regularly  in  the 
morning  or  at  bedtime  freely  diluted,  and  gouty  dyspeptics 
are  largely  dependent  upon  it  for  relief.  At  Vichy  and 
Wiesbaden  acute  attacks  are  known  to  occur  during  the 
use  of  the  mineral  waters,  but  this  result  is  not  limited 
to  the  sodic  waters,  and  probably  has  some  other  ex- 
planation. 

In  practice  we  can  afford  to  lose  sight  of  the  solvent 
power  of  potassium  bicarbonate  for  uric  acid,  and  of  the 
production  by  sodium  bicarbonate  of  an  insoluble  biurate, 
so  long  as  we  can  deal  successfully  with  the  more  essential 
requirement  of  limiting  the  supply  of  uric  acid  itself. 

In  conclusion,  we  adhere  to  the  view  that  the  bicarbonate 
and  citrate  of  potassium  are  of  use  as  antacids,  as  diuretics, 
and  as  alteratives ;  that  their  doses  should  not  be  large, 
nor  their  administration  long  continued,  but,  if  necessary, 
frequently  renewed.  Cases  of  marked  acidity  and  showing 
a  tendency  to  sthenic  articular  attacks  are  those  calling 
for  this  treatment. 

Sodium  bicarbonate  as  an  antacid  is  suited  to  asthenic 
cases,  and   to  the  sufferers  from   dyspepsia  with   torpid 


ALTERATIVE  REMEDIES  ACTING  ON  URIC  ACID    435 


liver.  Here,  again,  the  intermittent  administration  is 
preferable,  and  it  is  advisable  to  limit  the  strength  of 
the  doses  and  their  frequency. 

ALTERATIVE  REMEDIES  ACTING  ON  URIC  ACID. 

This  important  group  comprises  the  salicylates  and  the 
benzoates.  They  share  the  valuable  peculiarity  of  allowing 
the  urine  to  remain  acid,  whilst  increasing  the  elimination 
of  uric  acid.  The  formation  by  them  of  salicyluric  acid  and 
of  hippuric  acid  respectively  with  the  elements  of  uric  acid 
has  been  described  in  preceding  pages.  Their  beneficial 
action  is  not  limited  to  this  function.  Benzoic  acid  is 
a  valuable  stimulant  for  the  mucous  membranes,  and 
salicylic  acid  in  combination  with  sodium  acts  as  a  most 
efficient  cholagogue,  in  addition  to  its  antiseptic  property. 
Their  indications  in  individual  cases  of  chronic  gout  are 
thus  clearly  marked  out.  For  subjects  in  whom  any  de- 
pressing treatment  is  to  be  avoided,  and  whose  kidneys 
are  not  above  suspicion,  the  benzoate  of  potassium  may 
be  administered  in  doses  of  a  scruple,  combined  with 
a  drachm  of  succus  taraxaci  and  fifteen  drops  of  spirits 
of  chloroform.  In  other  cases  this  treatment  may  be 
made  to  alternate  for  periods  of  a  week  or  a  fortnight 
with  the  saline  treatment.  Guaiacum  may  with  advantage 
be  combined  with  the  benzoate. 

Sodium  salicylate  is  probably  one  of  our  most  useful 
drugs  in  chronic  gout,  but  its  use  must  be  restricted  to 
cases  free  from  renal  disease.  Lecorche  and  Haig,  its 
strenuous  advocates,  have  both  found,  soon  after  its  first 
administration,  a  marked  temporary  increase  in  the 
amount  of  uric  acid  in  the  urine  ;  this  is  followed  after 
three  or  four  days  by  a  progressive  decrease.  The  best 
results  are  obtained,  according  to  them,  by  a  continuous 
administration,  for  prolonged  periods,  in  daily  supplies  of 


436  GENERAL  ALTERATIVE  REMEDIES 

60  grains  or  more.  Lecorche  finds  that  it  not  only  de- 
creases the  amount  of  uric  acid  in  the  blood  and  lessens 
the  liability  to  attacks,  but  that  it  promotes  the  absorption 
of  the  deposits.  Haig  is  also  a  strong  believer  in  its 
efficacy  in  lessening  the  accumulation  of  uric  acid  in 
the  system.  Its  use  should  be  combined  with  careful 
attention  to  diet  and  hygiene. 

GENERAL  ALTERATIVE  REMEDIES. 

The  beneficial  action  of  the  members  of  this  group  is 
not  exerted  directly  on  the  uric  acid,  but  on  the  general 
metabolism,  and  in  the  case  of  some  of  them  on  the 
liver, 

Colchicum  was  formerly  prescribed  in  chronic  gout  by 
Sir  Henry  Holland,  and  by  some  other  physicians,  in  a 
continuous  fashion,  as  a  preventive.  Long  before  the 
introduction  of  the  salicylates.  Sir  A.  Garrod  had  expressed 
his  disapproval  of  that  practice,  thinking  that  it  would 
be  better  to  reserve  it  for  the  immediate  threatenings  of 
an  acute  attack.  We  are  now  much  less  dependent  upon 
its  use  than  ever  before,  even  in  acute  gout,  and  its 
continued  employment  as  a  prophylactic  in  the  chronic 
affection  is  probably  never  suggested. 

Iodide  of  potassium  and  iodine  are,  next  to  the  drugs 
which  have  been  mentioned,  our  most  efficacious  remedies 
in  chronic  gout,  and  the  iodide  has  long  enjoyed  a  well- 
deserved  reputation.  It  is  specially  useful  in  cases  pre- 
senting subacute  and  lingering  swellings  of  the  joints  with 
some  effusion,  in  the  painful  gout  of  the  sole  and  of  the 
heel,  in  the  myalgic  complications  of  gout,  and  in  the 
neuralgiae.  In  all  these  conditions,  in  order  to  obtain 
the  full  benefit  of  the  treatment,  the  dose  must  be  raised 
above  that  recommended  by  Sir  A.  Garrod  (3  grains) 
in  his  remarks  on  the  continuous  administration.     With 


GENERAL  ALTERATIVE  REMEDIES  437 

this,  as  with  all  other  drugs  in  chronic  gout,  we  must 
watch  the  results  and  gain  the  assurance  that  the  excre- 
tory power  of  the  kidney  is  equal  to  the  task  put  upon 
it.  Advanced  kidney  disease  is  a  contra-indication,  the 
imperfectly  excreted  drug  causing  irritation  of  the  skin 
and  an  iodine  rash.  Dr.  Burney  Yeo  mentions,  however, 
good  results  in  cases  of  '  albuminuria,  with  well-marked 
vascular  and  renal  changes,'  from  the  daily  administra- 
tion of  from  15  to  30  grains.  Where  the  albuminuria 
is  functional,  or  the  kidney  changes  not  of  the  incurable 
interstitial  variety,  it  may  be  desirable  to  obtain  for  the 
kidney  itself  a  share  of  the  wide-spread  beneficial  activity 
of  the  drug. 

In  cases  free  from  renal  complication,  the  treatment 
may  be  continued  for  long  periods,  the  doses  not  exceed- 
ing 15  to  20  grains  daily.  Periodical  interruptions  do  not 
interfere  with  the  usefulness  of  the  treatment. 

The  main  indications  for  the  administration  of  iodide 
of  potassium  are  fulfilled  in  a  higher  degree  by  the  tincture 
of  iodine.  Dr.  Mortimer  Granville  has  insisted  on  the 
value  of  this  preparation  even  in  acute  gout.  In  chronic 
gout,  especially  that  which  affects  the  fibrous  structures  in 
and  around  the  joints,  the  writer  can  strongly  recommend 
its  use  in  combination  with  iodide  of  potassium.  He  has 
found  great  benefit  from  it  also  in  the  painful  affections  of 
muscles  and  nerves.  In  the  tophaceous  variety  it  should 
also  be  tried,  the  indication  being  here  to  improve  and 
modify  the  general  metabolism  rather  than  to  influence 
the  biurate  deposited.  The  stimulating  and  '  warming  ' 
action  of  the  free  iodine  on  the  nerves  and  mucous  mem- 
branes is  of  great  value.  The  dose  will  vary  with  individual 
cases,  and  according  as  the  iodide  is  or  is  not  prescribed 
at  the  same  time.  Five  to  ten  minims  three  or  four  times 
daily  would  be  a  safe  amount  to  prescribe  in  ordinary 


438  GENERAL  ALTERATIVE  REMEDIES 

cases,  but  this  is  often  exceeded  by  the  writer  where  a 
stronger  effect  is  required.  The  tincture  becomes  almost 
palatable  with  the  addition  of  some  elixir  of  orange. 

Guaiacum*  ranks  high  among  the  active  remedies  in 
chronic  gout.  The  relief  which  it  gives  to  the  painful 
affections  of  the  fibrous  tissue  and  to  the  myalgise  is  a 
proof  of  its  usefulness.  Where  iodide  of  potassium  gives 
relief,  guaiacum  is  also  efficacious  ;  they  may  with  ad- 
vantage be  combined  :  the  writer  commonly  uses  them  in 
this  way.  In  the  fluid  form  the  insolubility  and  the  colour 
of  the  drug  are  an  objection,  but  it  may  conveniently  be 
taken  as  a  powder  in  cachets,  or  in  the  shape  of  tabloids. 

Sulphur  is  another  agent  of  great  and  acknowledged 
value  in  chronic  gout.  It  is  unnecessary  to  dwell  upon 
its  use  here,  since  we  shall  again  consider  it  in  connection 
with  mineral  waters.  Many  sufferers  are  unable  to  visit 
the  baths  and  drink  the  water.  For  them  the  administra- 
tion of  sulphur  in  mixture,   cachet,   or  tabloids   (Sir  A. 

*  Sir  A.  Garrod,  in  a  paper  read  before  the  Royal  Medical  and 
Chirurgical  Society  on  May  26,  1896,  has  again  expressed  the  very 
high  opinion  of  the  value  of  guaiacum  which  he  has  derived  from  a 
long  experience.  '  He  thinks  that  he  has  been  successful  in  establish- 
ing the  following  points  in  regard  to  its  action  : 

'  I.  Guaiacum  is  innocuous,  and  may  be  taken  for  an  indefinite  period 
of  time,  and  looked  upon  as  a  condiment  rather  than  as  a  drug — as 
harmless  as  ginger  or  any  other  condiment. 

'2.  Guaiacum  possesses  a  considerable  power,  but  less  than  colchicum, 
in  directly  relieving  patients  suffering  from  gouty  inflammation  of  any 
Dart  ;  it  may  be  given  whenever  there  is  but  little  fever. 

'  3.  Guaiacum  taken  in  the  intervals  of  gouty  attacks  has  a  con- 
siderable power  of  averting  their  recurrence  ;  in  fact,  it  is  a  very  powerful 
prophylactic. 

'  4.  Guaiacum  does  not  appear  to  lose  its  prophylactic  power  by  long- 
continued  use. 

'  5.  There  are  a  few  persons  who  cannot  readily  continue  the  use  of 
guaiacum  ;  for  such  cases  there  are  other  drugs  whose  action  is  in  some 
respects  similar  as  prophylactics  — perhaps  serpentary  is  one  of  the  most 
powerful  of  these.' 


GENERAL  ALTERATIVE  REMEDIES  439 

Garrod's  5-grain  compound  sulphur  tabloids  are  specially 
useful  where  the  aperient  effect  is  desired),  will  be  a  ready 
substitute,  though  nothing  will  replace  the  general  benefit 
conferred  by  the  change  of  surroundings  and  of  conditions. 
Mercury  is  too  important  an  alterative  not  to  deserve  a 
trial  where  other  remedies  fail.  For  reasons  upon  which 
we  need  not  dwell  again,  it  cannot  be  widely  recom- 
mended. Scudamore  laid  stress  on  the  evils  apt  to  follow 
its  injudicious  employment,  and  Garrod  states  that,  as  it 
possesses  no  controlling  power  over  gouty  inflammation, 
it  should  not  be  prescribed  otherwise  than  as  an  immediate 
cholagogue. 

The  administration  of  fractional  doses,  such  as  \  grain 
of  calomel  or  15  minims  of  the  solution  of  the  perchloride, 
is  free  from  the  danger  of  causing  any  mercurialism,  and 
it  has  been  well  borne  and  productive  of  benefit  when 
continued  for  a  few  days.  In  some  cases  where  anaemia 
is  marked,  and  iron  is  not  otherwise  well  assimilated,  the 
addition  of  a  small  proportion  of  mercury  may  lead  to  the 
best  results;  but  it  is  never  desirable  to  submit  any  patient 
to  a  prolonged  course  of  this  treatment,  and  the  indication 
only  arises  when  the  hepatic  functions  cannot  be  improved 
by  other  means. 

Arsenic  is  of  less  value  in  chronic  gout  than  in  rheu- 
matoid arthritis,  and  is  better  suited  to  the  treatment  of 
the  nervous  disorders  incidental  to  goutiness  than  to  the 
articular  form.  Nevertheless,  arguments  in  favour  of  its 
use  have  been  derived  from  its  undoubted  action  on 
metabolism  and  on  the  nutrition  of  epithelial  and  nervous 
structures,  and  from  the  existence  of  a  nervous  element 
in  all  forms  of  gout.  Again,  the  presence  of  minute  doses 
of  the  metal  in  various  mineral  waters  which  have  been 
found  beneficial  has  suggested  its  independent  employ- 
ment.    In  cases  where  special  indications  can  be  traced, 


440  THE  TONIC  TREA  TMENT 

whether  in  the  cutaneous,  the  nervous,  or  the  ahmentary 
system,  and  where  the  kidneys  are  in  a  healthy  state,  the 
remedy  might  be  safely  given  a  trial  with  the  usual  pre- 
cautions. 


THE  TONIC  TREATMENT  DIRECTED  TO  THE  BLOOD 
AND  TO  THE  VISCERAL  FUNCTIONS. 

We  have  dwelt  incidentally  upon  the  functions  of  the 
liver  and  of  the  kidney. 

The  treatment  of  the  cardiac  symptoms  arising  in  chronic 
gout  will  be  discussed  under  a  special  heading  in  connec- 
tion with  goutiness.  We  may  merely  refer  to  the  dis- 
tinction elsewhere  drawn  between  the  organic  group  of 
affections  which  are  more  likely  to  be  met  with  in  those 
advanced  in  years,  though  not  limited  to  old  age,  and 
those  of  a  partly,  if  not  wholly,  functional  character,  which 
are  capable  of  considerable  relief,  or  even  of  complete 
amendment. 

The  Treatment  of  the  Stomach. — Without  the  basis  of  an 
efficient  digestion  all  medication  is  futile.  In  that  sense 
the  stomach  claims  our  constant  attention  in  chronic 
gout.  The  improvement  of  the  digestion  is  the  essential 
means  to  an  improved  assimilation  and  metabolism.  It 
is  best  secured  by  hygiene  and  diet.  Deferring  these 
subjects  and  that  of  the  aggravated  dyspepsia  of  goutiness 
for  separate  consideration,  we  must  allude  to  the  treat- 
ment of  the  minor  gastric  disturbances  which  we  are,  in 
chronic  gout,  constantly  called  upon  to  correct.  They 
resolve  themselves  into  acidity  on  the  one  hand,  and  want 
of  tone  on  the  other.  The  acidity  is  to  be  subdued  by  the 
mild  alkaline  treatment.  Bicarbonate  of  potassium  will 
sometimes  be  necessary  ;  but  it  is  the  privilege  of  sodium 
bicarbonate  to  suit  both  the  acid  and  the  atonic  varieties. 


THE  TONIC  TREATMENT  441 

The    extreme  acidity  due    to    unhealthy  fermentation   of 
food  calls  for  the  administration  of  nitro-muriatic  acid. 

Even  in  the  absence  of  any  pronounced  dyspepsia,  we 
should  treat  the  debility  of  the  stomach,  and  our  tonics 
should  be  those  which  best  suit  the  digestion.  The  simple 
bitters  are  generally  appropriate  —  cascarilla,  quassia, 
chiretta,  Colombo,  gentian  ;  and  the  stronger  bitter  tonics 
— quinine,  nux  vomica,  or  strychnine — may  be  used  in 
alternating  succession.  The  addition  of  some  carminative 
or  aromatic,  such  as  ginger,  capsicum,  cardamoms,  cloves, 
is  usually  an  advantage. 

Serpentary  combines  the  aromatic  with  the  bitter  tonic 
property,  in  addition  to  diaphoretic  and  diuretic  pro- 
perties, which  have  led  to  its  employment  in  chronic 
rheumatism.  Sir  A.  Garrod*  has  recently  stated  his  belief 
in  the  power  for  good  of  this  drug  in  articular  gout  itself, 
particularly  in  the  gouty  inflammations  of  elderly  subjects, 
and  has  hinted  at  its  possessing  some  prophylactic  action 
analogous  to  that  of  guaiacum. 

This  gently  stimulating  and  tonic  stomachic  treatment 
remains  practically  the  same  as  that  adopted  by  Sydenham, 
whose  long  prescription  is  suggestive  of  the  value  which 
he  attached  to  gastric  tonics,  and  imitated  in  the  prepara- 
tion of  various  specifics,  such  as  the  Portland  powder, 
and,  more  recently,  the  Pistoja  powders.*!* 

The  remaining  indication  is  to  treat  the  anceniia  where 
it  exists.  Most  often  exercise,  sunlight,  and  pure  air  are 
amply  sufficient,  and  ansemia  suggests  their  more  liberal 
use.  In  subjects  deprived  of  these  advantages  iron  may 
be  needed ;  but  its  administration  is  not  always  a  simple 
matter :  the  liver  has  to  be  reckoned  with.    For  this  reason 

*  '  Proceedings  of  the  R.  Med.  and  Chir.  Soc.,'  May  26,  1896. 
t  Compounded  by  the  R.  R.  Benedictine  Sisters  at  Pistoja,  Tuscany 
(Burney  Yeo). 


442  THE  TONIC  TREATMENT 

the  milder  chalybeate  mineral  waters  are  found  the  most 
successful,  especially  if  drunk  at  the  health  resorts ;  but 
they  are  also  available  as  table  waters. 

If  prescribed  as  medicine,  the  milder  preparations  should 
be  selected.  It  may  be  desirable  in  some  cases  to  alternate 
the  administration  with  short  courses  of  arsenic,  or  the 
effect  of  both  metals  may  be  combined,  as  in  the  arseniate 
of  iron  pill  (yV  grain  or  ^  grain),  which  has  often  been 
recommended,  and  is  thought  to  be  a  beneficial  as  well 
as  a  safe  remedy. 


CHAPTER  XLVII. 

THE  LOCAL  TREATMENT  OF  CHRONIC  GOUTY 
ARTHRITIS. 

The  Value  of  Local  Measures  in  Chronic  Gouty  Arthritis. — 
The  importance  of  obviating  the  crippHng  effects  of  gout 
is  appreciated  by  patients,  and  must  be  steadily  borne  in 
mind  by  the  physician,  who  must  be  the  judge  of  the 
extent  to  which  movement  is  to  be  combined  with  rest  to 
the  joints  affected.  The  skin  of  the  gouty  Hmbs  needs 
careful  attention;  this  indication  includes  the  treatment 
of  the  local  oedema.  Lastly,  the  management  of  the  tophi 
and  of  the  intra-articular  deposits  requires  special  care, 
and  their  surgical  treatment  is  one  of  the  questions  for 
discussion. 

Relatively  trivial  measures  may  effect  much  by  assiduous 
use,  but  they  are  most  efficacious  when  resorted  to  early. 
This  is  a  sufficient  excuse  for  dwelling  upon  details,  which 
are  not  in  the  event  as  trifling  as  they  might  at  first 
appear. 

POSITION,  PASSIVE  MOVEMENT,  AND  MASSAGE. 

The  position  of  the  limb  is  not  a  matter  of  indifference 
where  the  articular  swelling  is  considerable.  By  reheving 
local  venous  congestion,  and  promoting  a  free  lymphatic 
drainage,  habitual  elevation  of  the  part  may  lessen  the  rate 
of  uratic  deposition ;  it  certainly  counteracts  the  stagna- 
tion inseparable  from  disuse. 


444    POSITION,  PASSIVE  MOVEMENT,  AND  MASSAGE 

The  local  oedema,  which  is  apt,  in  atonic  subjects,  to 
linger  about  the  gouty  joints,  is  best  treated  in  this  way ; 
but  the  circulation  may  be  aided  by  the  lateral  support  of 
an  ordinary  gauze-  or  light  flannel-bandage.  Where  it  is 
persistent,  the  hot  douche,  followed  by  sponging  with  a 
cold,  strong  solution  of  common  salt,  was  recommended 
by  Hume,  and  found  of  much  value  by  Garrod.  Judicious 
rubbing  or  massage  frequently  applied  may  answer  every 
purpose.  Both  forms  of  treatment  are  combined  at  the 
spas  frequented  by  the  gouty. 

The  full  advantage  of  posture  can  only  be  obtained 
by  raising  the  limb  considerably,  and  by  securing  complete 
freedom  of  the  large  veins  at  the  flexures. 

Rest  and  Movement. — Both  are  useful,  but  they  should 
be  duly  apportioned.  We  are  sufficiently  imbued  with 
the  necessity  of  rest  for  inflamed  structures.  In  gout  we 
have  perhaps  overlooked  the  opposite  indication,  which 
has  long  been  recognised  in  the  treatment  of  rheumatoid 
arthritis.  The  latter  shows,  even  in  the  semi-acute  stage, 
marked  tolerance  for  passive  movement,  in  spite  of  the 
pain  which  is  inseparable  from  it.  Movement  of  the 
gouty  joints,  in  spite  of  its  desirability,  has  been  regarded 
as  practically  contra-indicated  in  the  majority  of  cases. 
Sir  W.  Wade's  observations  have  thrown  new  light  upon 
this  question.  They  show  that  even  during  the  acute 
stage  the  bones  entering  into  the  formation  of  the  joint 
can  be  freely  manipulated  and  moved  without  causing 
any  pain,  provided  no  pressure  is  made  on  the  tender 
spots  external  to  the  joint. 

This  has  an  important  bearing  upon  the  treatment  of 
the  chronic  condition.  Passive  movement  applied  with 
gentleness  and  care  at  an  early  date  after  the  subsidence 
of  the  acute  symptoms  would  obviate  the  subsequent 
stiffness    and    the    occasional    occurrence    of    ankylosis. 


THE  LOCAL  MEDICINAL  TREATMENT  445 

Massage  should  next  be  called  to  aid,  and  this  may  be 
usefully  combined  with  the  preliminary  administration 
of  a  local  warm  bath,  or,  better  still,  of  a  local  vapour 
bath  which  allows  the  limb  to  be  raised  for  the  relief  of 
the  local  congestion. 

At  a  later  stage,  when  the  patient  is  able  to  go  about, 
massage  should  be  administered  in  its  most  efficient  form, 
according  to  the  Aix  plan,  under  a  stream  of  thermal 
water.  This  method  has  now  come  into  universal  use, 
and  can  be  applied  at  several  of  our  own  balneological 
stations.  The  internal  use  of  the  sulphurous  waters  is 
supposed  to  materially  assist  the  local  treatment. 

THE  LOCAL  MEDICINAL  TREATMENT. 

Remedies  have  been  locally  applied  for  the  treatment 
of  the  skin,  for  the  relief  of  the  articular  stiffness,  and  for 
the  solution  of  the  tophaceous  concretions. 

The  skin  suffers  not  only  through  the  general  gouty 
malnutrition,  but  through  want  of  proper  exercise,  and 
from  the  stretching  which  it  undergoes.  Passive  exercise 
is  to  be  supplied  by  friction,  combined  with  the  use  of 
gently  stimulating  embrocations.  Often,  however,  the 
integument  is  so  delicate  or  tender  that  simple  or 
camphorated  oil  is  the  only  suitable  application. 

The  articular  stiffness  and  thickening  call  for  rather 
stronger  liniments,  when  they  can  be  borne  by  the  skin. 
Small  blisters  have  been  occasionally  found  of  advantage 
by  Garrod.  Usually  they  are  best  avoided.  Simple 
camphor  liniment,  or  the  compound  camphor  liniment, 
or  liniments  containing  turpentine,  carefully  used,  or 
iodine  painted  over  the  joint,  will  produce  sufficient 
counter-irritation.  A  safe  and  useful  application  is  the 
soap  and  iodide  of  potassium  liniment  gently  rubbed  in 
and  worn  over  the  part  at  night. 


446  THE  LOCAL  MEDICINAL  TREATMENT 


The  solution  of  the  concretions  by  the  local  application 
of  alkahes  was  definitely  advocated  by  Scudamore  on  the 
strength  of  the  solvent  power  of  potash  for  uric  acid. 
He  recommended  as  an  application  equal  parts  of  liquor 
potassse  and  of  almond  milk.  The  same  principle  was 
adopted  by  Garrod,  to  whom  we  owe  the  safer  and  more 
effectual  treatment  by  lithium  carbonate  solution,  in  the 
proportion  of  5  grains  of  the  salt  to  i  ounce  of  rose- 
water.  This  is  suitable  for  continuous  application  under 
oil  -  silk,  and  has  been  found  remarkably  successful, 
causing  in  some  cases  the  entire  disappearance  of  the 
deposit.  A  popular  remedy  based  on  the  same  principle 
is  the  application  of  a  warm  solution  of  sodium  carbonate  ; 
but  even  solutions  of  potassium  carbonate,  originally  tried 
by  Garrod,  were  found  less  efficacious  than  the  lithia 
treatment. 

The  introduction  of  lithium  by  electrolysis  has  recently 
been  suggested  by  Labutat.*  A  similar  method  had 
previously  been  proposed  by  Edison."]" 

Solutions  of  piperazin,  lysidin,  and  other  similar  bodies, 
may  perhaps  be  found  serviceable  as  topical  applications. 

THE  SURGICAL  TREATMENT. 

Any  surgical  interference  with  joints  affected  with 
concretions  or  with  late  arthritic  changes  has  always  been 
regarded  with  disfavour.  It  must  be  admitted  that  many 
surgical  questions  which  had  been  considered  closed  need 
to  be  reopened  and  to  be  looked  at  again  from  the  altered 
standpoint  of  antiseptic  surgery.  Gout  will  probably  not 
form  an  exception  to  this ;  but  it  is  doubtful  whether  the 
decisions  arrived  at  on  further  consideration  will  much 

*  Gaz.  des  Hopttaux,  1894,  vol.  Ixvii.,  p.  1318  (quoted  by  Dr.  Archi- 
bald Garrod,  Year-Book  of  Treatment  for  1896). 
f  Cf.  Year-Book  of  Treatment^  1891,  p.  158. 


THE  SURGICAL  TREATMENT  447 

differ  from  those  already  given.  An  impression  has 
prevailed  that  any  w^ounds  inflicted  in  the  neighbourhood 
of  gouty  joints  show  an  imperfect  tendency  to  heal.  On 
the  other  hand,  Dr.  Ord  ('  St.  Thomas's  Hospital  Reports,' 
1872)  refers  to  the  opposite  tendency  as  having  been 
observed  by  him,  and  gives  a  remarkable  instance  in 
point  of  a  joint  completely  healing  after  the  spontaneous 
discharge  of  a  very  large  amount  of  unhealthy  debris  and 
uratic  deposit.  There  can  be  no  question  that  the 
vitality  of  tissues  is  depressed  by  gout,  and  that  they 
are  liable,  not  only  to  the  special  inflammation  which 
we  recognise,  without  quite  understanding  it,  as  '  gouty,' 
but  also  to  erysipelas  ;  the  supervention  of  the  latter  is 
regarded  as  the  main  danger  to  be  dreaded  as  the  result 
of  surgical  interference. 

In  the  ear,  tophi  may  be  punctured  and  slowly  evacuated 
without  any  serious  risk.  In  the  vicinity  of  joints,  this 
proceeding,  as  pointed  out  by  Garrod,  is  hazardous,  and 
may  lead  to  prolonged  suppuration,  not  only  in  the  tophi 
operated  upon,  but  in  the  joint  with  which  they  sometimes 
communicate.  Although  small  incisions  have  often  proved 
harmless,  and  have  been  the  means  of  diminishing  the 
size  of  the  accumulations,  the  operative  treatment  is  not 
one  to  be  recommended,  even  with  the  help  of  antiseptic 
precautions. 

When  spontaneous  nlceration  takes  place  over  a  large 
concretion,  the  continuous  application,  under  an  antiseptic 
dressing,  of  the  lithium  carbonate  in  a  boracic  acid  solu- 
tion will  fulfil  a  doable  purpose,  and  may  be  the  means  of 
rapidly  diminishing  the  size  of  the  swelling. 


CHAPTER  XLVIII. 

TREATMENT  OF  METASTATIC  GOUT  OF  THE 
VISCERA. 

We  shall  limit  the  present  remarks  to  the  acute  visceral 
crises  distinctly  traceable  to  the  influence  of  an  abrupt 
cessation  of  the  acute  arthritic  symptoms,  in  contradistinc- 
tion to  the  visceral  complications  observed  in  the  state  of 
goutiness,  which  are  usually  independent  of  any  declared 
gouty  attack  in  the  joints.  The  treatment  of  the  latter  is 
considered  in  separate  chapters. 

Retrocedent  gout  is,  fortunately,  not  common,  less 
common  now  than  formerly ;  and  we  need  only  refer  to 
its  three  chief  varieties  :  the  gastro-intestinal,  the  cardio- 
pulmonary, and  the  cerebral. 

THE  GASTRO-INTESTINAL  FORM. 

An  obvious  indication  has  reference  to  the  cause  of  the 
trouble.  It  is  applicable  to  all  the  varieties  of  retrocedent 
gout ;  and  the  same  treatment  is  called  for  in  each  of 
them.  We  should  endeavour  to  induce  a  renewal  of  the 
gouty  inflammation  in  the  joint  from  which  it  has  dis- 
appeared. The  simplest  method  is  to  apply  mechanical 
irritation  to  the  articular  surfaces  by  passive  movement  of 
the  joint,  combined  with  some  pressure — a  proceeding  the 
harshness  of  which  is  justified  only  by  the  critical  state  of 


THE  GASTRO-INTESTINAL  FORM  449 

the  patient.  Superficial  counter-irritation  is  also  to  be 
applied  in  the  shape  of  the  mustard  foot-bath  and  mustard- 
leaves.  Blistering  is  not  called  for,  as  it  adds  a  trouble- 
some local  complication  to  existing  difficulties. 

Meanwhile,  the  first  of  the  symptomatic  indications  is 
the  intense  depression  of  the  patient.  Stimulating  remedies 
are  required.  Brandy  will  probably  have  been  adminis- 
tered, and  its  cautious  use  may  be  sometimes  continued  ; 
but  there  are  obvious  objections  to  its  unlimited  employ- 
ment, and  commonly  the  stomach  will  refuse  to  retain  it. 
Sal  volatile  and  ether,  reinforced  by  carbonate  of  ammonia, 
may  be  administered  in  chloroform-water;  or  they  may  be 
prescribed  in  an  effervescing  draught,  which  should  not  be 
too  bulky. 

If  the  stomach  should  be  intolerant  of  these  remedies 
also,  we  are  able  to  fall  back  upon  the  use  of  smelling-salts, 
the  subcutaneous  injection  of  ether,  and  the  rectal  injec- 
tion of  brandy,  of  coffee,  or  of  a  solution  of  caffein.  In 
this  way  the  necessary  stimulation  can  be  secured  in  spite 
of  the  vomiting. 

Another  urgent  indication  is  the  often  severe  gastric 
pain.  This  is  to  be  met  by  the  local  application  of  wet  or 
of  dry  fomentations,  sprinkled  with  two  teaspoonfuls  of 
laudanum.  If  very  severe,  the  pain  may  call  for  the  sub- 
cutaneous injection  of  a  quarter  of  a  grain  of  morphia.  Sir 
A.  Garrod  recommends  counter-irritation  to  the  epigastrium 
and  left  hypochondrium. 

Vomiting  is  to  be  promoted,  according  to  the  same 
authority,  by  diluents.  There  does  not  seem  to  be  any 
object  in  keeping  it  up  after  the  irritating  gastric  contents 
have  been  discharged.  The  best  way  to  subdue  it  is  to 
allow  the  stomach  absolute  physiological  rest,  and  to  keep 
up  the  strength  by  stimulants  administered  per  rectum. 

If  there  should  be  much  flatulency,  ether  capsules,  fol- 

29 


450  THE  GASTRO-INTESTINAL  FORM 

lowed  by  a  draught  of  water  as  hot  as  can  be  borne,  will 
probably  cause  the  partial  expulsion  of  the  gas,  whilst 
acting  as  a  temporary  stimulant. 

If  there  should  be  any  constipation,  this  should  be 
relieved  by  two  or  three  grains  of  calomel  placed  on  the 
tongue,  followed,  after  the  lapse  of  an  hour,  by  a  common 
enema.  The  calomel  may  also  assist  in  checking  the 
vomiting. 

More  difficult  to  treat  are  those  cases  in  which  diarrhoea 
is  associated  with  the  vomiting.  We  are  deprived  of  the 
help  of  rectal  medication  and  feeding,  so  long  as  the  purging 
continues.  We  must  endeavour  to  control  the  latter  by 
starch  and  opium  enemata  at  opportune  moments,  and  by 
lead  and  opium  suppositories. 

Any  symptoms  of  gastric  inflammation  would  suggest, 
according  to  Sir  A.  Garrod,  the  application  of  leeches,  and 
internally  alkalies,  combined  with  sedatives  and  hydro- 
cyanic acid.     He  regards  this  condition  as  decidedly  rare. 

THE  CARDIO-PULMONARY  ATTACKS. 

The  secondary  disturbance  of  the  circulation  from  which 
the  lung  suffers  as  a  result  of  the  cardiac  difficulty  justifies 
the  use  of  this  joint  name,  which  is  also  descriptive,  the 
symptoms  usually  including  those  of  pulmonary  congestion 
and  dyspnoea. 

There  are  two  forms  to  the  cardiac  seizures — the  anginal, 
with  predominating  pain  and  dyspnoea,  and  the  syncopal, 
with  prevailing  faintness.  Both  forms  are  usually  com- 
plicated with  a  gastric  factor.  Indeed,  some  observers 
regard  the  cardiac  crises  as  mainly  gastric  in  origin. 

The  treatment  is  in  its  essentials  the  same  for  both 
forms.  Brandy  is  the  immediate  indication,  and  the 
various  methods  of  stimulation  suggested  for  the  relief  of 
the  depression  of  the  gastric  crises  are  also  called  for.     In 


THE  CARDIO-PULMONARY  ATTACKS  451 

addition,  however,  special  measures  are  required  in  each 
of  the  varieties. 

In  the  syncopal  attack  the  following  treatment  should 
be  applied  immediately  : 

1.  The  patient  lying  quite  flat,  the  foot  of  the  bed  or 
sofa  is  to  be  raised  so  as  to  cause  the  head  to  be  slightly 
lower  than  the  trunk. 

2.  Hot  sponges,  wrung  out  of  boiling  water,  should  be 
applied  to  the  nape  and  to  the  forehead. 

3.  Heat  and  friction  should  be  freely  used  to  the  ex- 
tremities, and  a  warm  application  placed  over  the  epigas- 
trium. 

In  the  anginal  form  (which,  it  must  be  understood,  is  not 
necessarily  in  this  case  true  angina  pectoris,  though  many 
cases  have  been  wrongly  described  as  gouty  metastasis  to 
the  heart  which  really  were  of  that  nature),  in  addition  to 
the  stimulating  treatment  described,  the  inhalation  of 
nitrite  of  amyl  is  the  first  indication,  and  counter-irrita- 
tion, by  means  of  hot  poultices  or  of  a  mustard-leaf,  should 
be  applied  to  the  praecordial  and  to  the  epigastric  regions. 
It  is  important  to  administer  the  stimulants  as  warm  as 
possible,  in  order  to  increas-e  their  effect. 

Meanwhile,  in  both  cases,  the  usual  indications  are  to 
be  carried  out  which  have  been  described  at  the  beginning 
of  this  chapter,  in  the  hope  that  the  gouty  arthritis  may 
be  revived. 

THE  CEREBRAL  ATTACKS. 

Whether  they  take  the  congestive  form  or  the  paralytic, 
these  seizures  are  always  the  source  of  great  alarm. 

The  congestive  attack,  when  its  dependence  upon  intra- 
cranial hypersemia  is  unmistakable,  can  only  be  adequately 
dealt  with  in  one  way,  by  venesection,  which  is  most 
effectual  when  practised  in  the  neck.     Should  there  be 


452  THE  CEREBRAL  ATTACKS 

great  objection  to  this,  not  fewer  than  six  leeches  should 
be  appHed  to  the  mastoid  region.  Five  grains  of  calomel 
should  be  placed  on  the  tongue,  and  a  turpentine  enema 
may  be  administered  without  delay,  and  followed,  if  neces- 
sary, in  one  or  two  hours  by  a  common  injection. 

In  the  paralytic  form  there  may  be  no  evidence  of  any 
congestion  complicating  the  paralysis ;  and  in  cases  in 
which  there  is  neither  rise  of  temperature  nor  flush,  the 
question  as  to  the  abstraction  of  blood  will  be  both 
important  to  discuss  and  difficult  to  settle.  Where  no 
major  objection  is  raised,  bleeding  will  probably  be  of  use 
in  producing  an  alteration  in  the  intracranial  circulation, 
tending  either  to  relieve  hypersemia  or  to  modify  the 
ischsemia  to  which  we  have  already  referred  as  the  more 
likely  condition.  Or  a  via  media  may  be  adopted,  and 
leeches  applied.  In  this  case  also  the  administration  of 
calomel,  and  relief  of  the  bowels,  are  important  indica- 
tions. When  these  points  have  been  attended  to,  as  well 
as  the  general  treatment  applicable  to  retrocedent  gout, 
our  attitude  must  be  one  of  expectancy.  Time  only  will 
decide  whether  the  nature  of  the  seizure  is  genuinely 
apoplectic  or  simply  retrocedent.  In  other  cases,  however, 
we  may  find  indications  from  the  first  of  the  relatively 
benign  and  purely  functional  character  of  the  symptoms. 


CHAPTER  XLIX. 

THE  TREATMENT  OF  GOUTINESS  AND  OF 
ITS  SYMPTOMS. 

Goutiness,  whether  inherited  or  acquired,  may  be  viewed 
as  potential  gout.  Its  treatment,  clearly,  must  differ  from 
that  of  actual  gout ;  it  is  essentially  preventive.  The 
hygienic  and  the  dietetic  treatment,  which  will  be  described 
further  on,  belong  therefore  in  a  special  degree  to  gouti- 
ness. In  respect  of  hygiene  and  of  diet,  the  treatment  of 
gout  is  identical  with  that  of  goutiness  ;  both  affections 
agree  also  closely  in  all  those  indications  which  are  mainly 
constitutional. 

The  subjects  of  goutiness  are  liable  to  the  same  tendency 
to  acidity  and  to  lithgemia  as  sufferers  from  gout.  In 
goutiness,  however,  the  articular  symptoms  are  not  to  the 
front,  and  there  is  not  necessarily  always  a  uratic  factor 
to  treat. 

The  more  active  treatment  of  goutiness  is  directed  to 
the  symptoms.  These  are  so  multifarious  and  identified 
with  derangements  of  such  a  variety  of  functions  that  we 
can  only  deal  here  in  broad  outline  with  the  most  important 
among  them.  We  propose  to  consider  them  in  the  follow- 
ing groups :  The  hepatic,  the  renal,  the  gastric,  the  cardiac, 
the  pulmonary,  the  cutaneous,  the  neuralgic,  and  the 
neurotic.  In  all  these,  the  gouty  factor  has  to  be  borne 
in  mind  ;  but  in  each  of  them  it  is  some  particular  function 
or  organ  which  claims  our  immediate  attention. 


454  THE  HEPATIC  DERANGEMENTS 

THE  HEPATIC  DERANGEMENTS. 

In  addition  to  gouty  glycosuria  and  diabetes,  which  are 
conveniently  classified  under  this  heading,  two  forms  of 
hepatic  disturbance  are  commonly  observed  in  goutiness 
— the  simple  congestive  and  the  biliary  form.  In  neither 
of  these  is  there  any  special  feature  sharply  distinguishing 
the  attacks  from  those  occurring  in  other  subjects.  The 
peculiarity  resides  rather  in  their  marked  tendency  to  re- 
currence, in  the  facility  with  which  they  are  induced  by 
trifling  causes,  in  their  resistance  to  ordinary  measures  of 
treatment,  and  in  the  relief  afforded  by  those  which  are 
directed  to  the  constitutional  factor. 

Both  varieties,  but  especially  the  biliary,  often  present 
a  remarkable  neurotic  element,  the  depression  being  out 
of  proportion  with  the  organic  disturbance,  and  the  causa- 
tion being  sometimes  almost  purely  nervous. 

The  congestive  form  is  more  often  witnessed  at  the 
gouty  period  of  life  and  in  those  who  may  have  suffered 
slightly  from  manifest  gout  at  an  earlier  date,  and  have 
lapsed  into  a  state  of  goutiness.  Relatively  slight  depar- 
tures from  a  strict  diet,  or  deprivation  from  the  habitual 
exercise,  or  any  circumstances  lowering  temporarily  the 
energy,  may  suffice  to  originate  the  congestion.  When 
this  is  mainly  due  to  some  accidental  error  in  diet,  and 
coupled  with  trivial  gastric  or  intestinal  irritation,  the 
treatment  by  general  rest  and  abstinence  from  solid  food, 
and  by  hepatic  purges,  will  afford  the  necessary  relief. 
In  other  cases  the  causation  is  less  obvious,  and  the 
customary  remedies  fail  to  relieve  completely.  The  first 
essential  in  dealing  with  the  affection  is  a  thorough  revision 
of  the  diet.  Wine  must  be  given  up ;  indeed,  alcohol  in 
any  form  may  have  to  be  avoided,  and  a  dietary  must  be 
devised  which  shall  be  absolutely  bland  and  non-irritating. 


THE  HEPATIC  DERANGEMENTS  455 

Such  simple  medicines  as  Carlsbad  salts  taken  in  hot  water 
every  morning,  and  a  mixture  containing  citrate  of  potash 
and  nux  vomica,  will  soon  lead  to  improvement,  and  this 
will  be  the  more  rapid  if  the  patient  can  be  induced  to 
gradually  increase  the  daily  amount  of  exercise.  By  far 
the  most  effectual  treatment  is  a  visit  to  Harrogate  or  to 
Carlsbad. 

The  biliary  form  is  not  infrequently  witnessed  in  young 
subjects  who  have  never  suffered  from  gout,  but  who 
inherit  a  strong  gouty  tendency.  The  familiar  paroxysmal 
biliary  attacks  are  often  of  this  nature  ;  they  are  specially 
common  in  the  female  sex.  We  need  not  dwell  upon  their 
treatment,  since  they  run  a  definite  course  and  undergo 
a  spontaneous  cure.  Our  object  should  be  to  obviate  their 
recurrence.  The  other  variety,  to  which  males  are  more 
liable,  is  chronic,  and  apt  to  be  exceedingly  obstinate.  It 
is  associated  with  dyspepsia  and  acidity,  and  is  subject  to 
constant  exacerbations  variously  induced  by  indigestion, 
by  chill,  and  by  moral  influences,  the  patients  being,  by 
constitution  and  also  as  a  result  of  invalidism,  peculiarly 
nervous.  In  both  forms  we  infer,  in  addition  to  a  catarrhal 
condition  of  the  biliary  mucous  membrane,  a  spasmodic 
affection  of  its  muscular  coat,  and  we  are  reminded  of  the 
similar  affections  of  the  bronchial  mucous  membrane  to 
which  some  of  the  subjects  of  inherited  goutiness  are  liable 
from  an  early  age.  The  management  of  the  chronic 
ailment  is  difficult  when  the  advantage  of  a  suitable  and 
protecting  climate  cannot  be  secured,  exposure  to  cold 
winds  being  almost  invariably  followed  by  a  recrudescence 
of  the  symptoms.  The  remaining  indications  have  reference 
to  the  neurotic  tendency,  to  the  dyspepsia,  and  to  the 
hepatic  torpor.  Of  all  these,  the  most  essential  is  a 
regulation  of  the  diet  such  as  will  restore  a  healthy  nutri- 
tion ;  and  a  judicious  hygiene,  which  for  young  subjects 


456  THE  HEPATIC  DERANGEMENTS 

implies  more  often  the  precept  of  rest  than  that  of  addi- 
tional exercise,  will  aid  powerfully  towards  an  improved 
digestion.  The  medicinal  treatment  is  that  suited  to  acid 
and  nervous  dyspepsia,  and  to  biliary  catarrh.  Both  indi- 
cations will  be  effectually  fulfilled  by  a  seasonable  visit  to 
one  of  the  Continental  spas. 

We  have  alluded  in  previous  sections  of  this  work  to 
another  form  of  gouty  affection  of  the  liver  occurring  at 
a  later  period  of  life,  and  apt  to  be  severe.  The  neurotic 
and  the  spasmodic  elements  are  not  here  prominent  factors. 
The  chief  feature  seems  to  be  an  intimate  disturbance  of 
the  secreting  activity  of  the  hepatic  cells,  originally  induced 
by  a  catarrh  of  the  fine  biliary  ducts.  The  same  general 
indications  as  regards  diet  apply  to  this  affection  also. 
Its  early  treatment  implies  rest  in  bed  and  careful  medica- 
tion. Gentle  hepatic  stimulation  by  '  fractional '  doses  of 
mercury,  the  administration  of  sodium  sulphate  and  bicar- 
bonate with  enough  carbonate  of  ammonium  to  obviate 
any  depression,  and  a  mild  bitter  infusion,  are  the  first 
indications.  Warmth  is  a  special  requirement ;  and  the 
hot-air  bath  administered  in  bed  may  be  a  useful  adjunct 
to  other  diaphoretic  measures.  Diuresis  will  be  promoted 
by  a  diet  at  first  exclusively  of  milk.  A  bdominal  and  hepatic 
massage  may  be  resorted  to  as  soon  as  the  hepatic  tender^ 
ness  shall  have  subsided.  A  course  of  sodium  salicylate 
and  of  chloride  of  ammonium  may  now  be  combined  with 
the  sodium  bicarbonate.  An  alternative  treatment  which 
can  be  safely  administered  with  much  benefit  is  the  com- 
bination of  sodium  benzoate  20  grains,  succus  taraxaci 
I  drachm,  elixir  of  orange  i  drachm,  and  guaiacum  mixture 
to  an  ounce;  to  be  taken  three  or  four  times  in  twenty-four 
hours.  In  obstinate  cases  the  preparations  of  iodine  and 
of  sulphur  might  also  be  thought  of.  After  the  onset  of 
convalescence,  change  to  a  genial  and  warm  climate  should 


GOUTY  GLYCOSURIA  AND  DIABETES  457 

be  arranged,  and  in  due  course  the  hepatic  treatment 
should  be  cautiously  applied  at  Harrogate  or  at  one  of 
the  sulphated  sodium  mineral  springs.  Attention  to  diet 
will  continue  to  be  of  primary  importance.  The  question  of 
vegetarianism  is  one  for  earnest  consideration  in  these  cases. 

Gouty  glycosuria  occurs  in  every  degree  and  combina- 
tion. Its  presence  is  always  a  serious,  but  usually  not 
an  alarming,  complication.  Under  careful  management 
patients  often  live  for  many  years,  sometimes  almost 
wearing  out  the  disease.  The  renal  complication  is  that 
most  to  be  dreaded.  When  the  specific  gravity  of  the 
urine  is  habitually  low  in  spite  of  the  sugar  present  in 
it,  we  shall  suspect  renal  inadequacy,  and  additional 
attention  will  be  needed  in  the  regulation  of  the  nitro- 
genous supplies.  On  the  other  hand,  especially  in  the 
aged,  a  slight  degree  of  albuminuria  does  not  of  necessity 
signify  damage  to  the  kidney. 

The  essential  part  of  our  treatment  concerns  diet.  Great 
benefit  will  accrue  from  spells  of  two  or  three  days  in 
bed,  at  intervals  of  two  or  three  weeks,  or  at  such 
intervals  as  may  be  indicated,  for  the  express  purpose 
of  resting,  not  only  the  nervous  system,  but  the  liver, 
kidney,  and  stomach,  by  an  exclusive  milk  diet.  Prolonged 
treatment  of  this  kind  is  not  desirable  in  those  of  mature 
years,  lest  the  habit  of  exercise  be  lost.  Whilst  in  bed 
they  may  with  advantage  be  treated  with  general  massage. 

Diet  at  other  times  should  be  of  a  mixed  kind,  avoiding 
excess  both  in  the  saccharines  and  in  the  nitrogenous 
supplies.  The  latter  might  with  great  advantage  be 
obtained  from  vegetable  sources,  from  eggs  and  from 
fish  rather  than  from  heavy  meats,  soups,  and  sauces. 
Milk  should  not  be  taken  with  meals ;  but,  during  their 
intervals,  its  use  to  the  extent  of  i^-  to  2  pints  a  day 
will  be  most  beneficial  as  a  food,  as  an  alkalizer,  and  as 


458  GOUTY  GLYCOSURIA  AND  DIABETES 

a  means  of  '  washing  out '  of  the  system  waste  products- 
Not  the  least  of  its  functions  is  to  nourish  the  patient 
during  the  night,  and  also  during  the  longer  intervals 
between  meals,  and  to  obviate  the  necessity  for  heavy 
meals,  and  particularly  for  heavy  meat  meals,  which  are 
most  undesirable.  At  meals  whisky  or  a  little  bordeaux 
are  desirable  as  stomachics. 

The  medicinal  treatment  has  many  aspects.  These  we 
can  only  point  out  in  a  general  way.  The  main  hepatic 
indications  are  :  Gentle  derivation  by  the  alkaline  sul- 
phates, chlorides,  and  bicarbonates  ;  stimulation  by  oc- 
casional small  doses  of  Plummer's  pill  or  of  podophyllin, 
and  by  the  administration  of  sodium  salicylate  (if  not 
contra-indicated),  of  potassium,  sodium,  or  ammonium 
benzoate,  of  guaiacum,  of  iodine,  and  perhaps  of  sulphur. 
Arsenic  has  occasionally  been  prescribed.  These  remedies 
will  fulfil  the  additional  indication  arising  from  goutiness, 
which  would,  however,  be  most  successfully  met  by  a  course 
of  treatment  at  some  mineral  spring  in  a  favoured  climate. 
The  choice  of  the  mineral  water  is  much  less  important 
in  this  affection  than  that  of  the  physician.  The  simpler 
waters  will  often  prove  beneficial ;  but,  if  the  patient  be 
sent  to  the  stronger  springs,  though  greater  benefit  may  be 
derived,  the  risks  are  also  greater,  and  the  result  will 
entirely  depend  upon  the  judgment  and  care  with  which 
the  special  treatment  and  the  diet  and  hygiene  may  have 
been  regulated  by  the  patient's  medical  adviser. 

Gouty  glycosuria  and  diabetes  really  call  for  little 
medicinal  treatment  beyond  that  which  belongs  to  gouti- 
ness. In  dealing  with  the  latter,  we  should  not  lose  sight 
of  the  fact  that  in  old  age  the  gouty  tendency  gradually 
loses  strength,  and  that,  meanwhile,  the  diuresis  associated 
with  glycosuria  carries  out  for  the  patient  one  of  the 
therapeutic  indications. 


GOUTY  GLYCOSURIA  AND  DIABETES  459 

The  bicarbonate  and  the  sulphate  of  sodium  are  the 
medicines  suited  to  the  greater  number.  It  is  not  desirable 
to  render  the  urine  alkaline,  and  from  that  point  of  view 
the  benzoates  and  the  salicylates  are  preferable  to  the 
potassium  bicarbonate  ;  but  the  salicylate  is  often  contra- 
indicated  by  the  presence  of  albuminuria.  In  some  middle- 
aged  and  relatively  robust  subjects  in  whom  gout  takes  the 
leading  part,  and  the  glycosuria  is  shght,  more  active  medi- 
cation may  be  wanted,  including  potassium  bicarbonate 
or  citrate,  and  small  doses  of  colchicum.  More  often 
ammonium  carbonate,  strychnine,  and  quinine  or  bark 
are  required  at  intervals,  or  should  be  combined  with  the 
sodium  bicarbonate. 

The  liver  itself  does  not  often  provide  us  with  any  indi- 
cations. Any  congestion  or  enlargement  would  suggest 
the  systematic  use  of  laxatives,  and  the  occasional  use  of 
cholagogue  remedies  ;  but  strong  purges  are  to  be  depre- 
cated. Mechanical  treatment  of  the  liver  is  less  called  for 
than  general  and  abdominal  massage.  Great  benefit  is 
often  obtained  at  mineral  springs,  and  a  great  part  of  this  is 
probably  due  to  hygiene  and  diet.  Neuenahr,  in  Germany, 
has  long  enjoyed  considerable  repute.  Of  late  years 
Contrexeville  and  Vittel,  in  the  Vosges,  have  rapidly  risen 
into  popularity. 

THE  TREATMENT  OF  THE  KIDNEY. 

A  discussion  of  the  treatment  of  acute  and  chronic 
nephritis  is  unnecessary.  In  early  stages  of  goutiness  the 
kidney  is  not  organically  affected  ;  but  it  indirectly  suffers 
from  results  of  an  imperfect  general  metabolism,  probably 
analogous  to  those  which  Semmola  (whose  views  we  quote 
from  Dr.  Haig's  account  of  them)  regards  as  the  cause  of 
Bright's  disease.  According  to  Semmola,  this  depends, 
in  its  first  stage,  on  a  diminished  formation  of  urea  and 


46o  THE  TREATMENT  OF  THE  KIDNEY 

an  increased  diffusibility  of  the  albumen  circulating  in  the 
blood.  The  kidney  lesion  he  would  regard  as  secondary, 
and  as  due  to  local  congestion  and  irritation  from  a  con- 
tinued passage  of  a  foreign  albumen.  The  albuminuria 
he  considers  to  be  proportional  to  the  blood  lesion  rather 
than  to  the  kidney  lesion.  Semmola  attributes  the  fall  in 
urea  formation  to  the  incomplete  combustion  of  certain 
albumens,  owing  to  failure  of  function  on  the  part  of  liver 
and  skin — the  skin  in  particular  undergoing,  as  he  shows, 
considerable  atrophy  in  Bright's  disease. 

The  renal  treatment  would  thus  be  directed  less  to  the 
kidneys  than  through  them  to  the  gouty  state.  It  con- 
sists mainly  of  two  methods  :  the  treatment  by  '  flushing,' 
and  the  alkaline  treatment. 

1.  The  use  of  copious  draughts  of  water  is  a  very  ancient 
prescription,  too  little  followed  out,  or  we  should  hear  less 
of  gout.  The  advantages  of  this  practice  are  manifold. 
To  the  kidney  itself  it  must  be  of  service  by  clearing  the 
secreting  cells  of  any  arrears,  by  refreshing  them,  by 
stimulating  their  oxidation  and  metabolism,  and  thus 
promoting  their  nutrition.  Excessive  flushing  may  bring 
with  it  the  risk,  pointed  out  by  Sir  W.  Roberts,  of 
diminishing  in  the  urinary  secretion  the  proportion  of 
chlorides  and  of  pigment,  and  therefore  the  solvent  power 
for  uric  acid.  But  the  mere  bulk  of  fluid  which  passes 
through  the  kidney  provides  for  the  solubility  of  the  uric 
acid  within  it,  and,  as  pointed  out  by  Roberts,  any  precipi- 
tation which  may  occur  within  the  bladder  is  a  minor  evil 
compared  with  the  sedimentation  of  uric  acid  as  sodium 
urate  in  the  kidneys  or  in  the  tissues.  Moreover,  it  is 
unlikely  that  any  person  properly  treated  in  respect  of 
the  gout  should  fail  to  be  safeguarded  against  the  lesser 
trouble  of  gravel. 

2.  The   alkaline   treatment  has  already  been    discussed. 


THE  TREATMENT  OF  THE  KIDNEY  461 

As  shown  by  Sir  W.  Roberts,  the  increased  alkahne  sup- 
phes  ultimately  pass  entirely  through  the  kidney.  Although 
these  may  be  quite  inadequate  to  make,  as  local  solvents, 
an  impression  upon  any  peripheral  uratic  deposits,  they 
must  tell  upon  the  kidney  for  better  or  for  worse.  We 
regard  the  effect  as  a  favourable  one,  the  tissue  reactions 
being  faulty  in  their  tendency  to  acidity  and  to  imperfect 
oxidation,  for  which  alkalies  are  a  direct  corrective.  From 
the  broad  standpoint  of  the  theory  of  renal  inadequacy, 
any  remedy  tending  to  improve  the  condition  of  the  kidney 
is  worthy  of  consideration  ;  and  the  general  effects  of  the 
alkalies,  independently  of  their  solvent  power  for  uric  acid, 
are  such  as  to  cause  them  to  be  recommended  for  affec- 
tions of  the  urinary  tract. 

The  influence  of  alkalies  upon  the  causes  of  gout  is  a 
matter  for  separate  consideration.  Gout  may  recur  under 
their  use,  as  Sir  W.  Roberts  and  others  have  observed  in 
practice  ;  but  it  remains  a  question  whether  the  patient's 
ultimate  condition  may  not  have  been  much  less  severe 
than  it  otherwise  might  have  been,  and  whether  the  kidney 
may  not  have  escaped,  thanks  to  the  method  adopted, 
those  destructive  changes  which  are  the  most  dreaded 
results  of  gout.  The  vicarious  relief  to  be  afforded  to  the 
kidney  by  action  on  the  skin  and  bowel,  and  the  direct 
relief  to  be  secured  by  an  avoidance  of  all  nitrogenous 
excess  and  of  irritating  foods  or  beverages,  are  subjects  for 
our  further  consideration. 

THE  TREATMENT  OF  URIC  ACID  GRAVEL. 

We  have  already  referred  to  the  occurrence  of  gravel  as 
an  evidence  of  goutiness,  and  to  the  frequency  of  this 
symptom  in  children  inheriting  the  tendency.  It  should 
not  be  understood,  however,  that  this  connection  invariably 
obtains.     Although  gout  is  associated  with  an  excess  of 


462         THE  TREATMENT  OF  URIC  ACID  GRAVEL 

uric  acid,  it  is  important  to  note  that  an  excess  of  uric 
acid,  even  a  considerable  excess,  is  not  necessarily  gout. 
As  Sir  W.  Roberts  has  expressed  it,  '  all  depends  upon 
which  side  of  the  kidney  the  proportion  is  disturbed.'  In 
gout,  the  sedimentation  originates  within  the  blood  district : 
lithuria,  gravel,  and  stone  are  identified  with  a  transrenal 
sedimentation  within  the  urinary  district.  Sir  W.  Roberts 
points  out  that  the  urine,  once  secreted,  being  practically 
excluded  from  vital  influences,  the  fate  of  its  constituents, 
and  of  uric  acid  in  particular,  is  a  mere  question  of  chemistry 
and  physics.  Uric  acid  in  the  urine  is  clearly  a  calculable 
quantity.  Not  so  the  circulating  uric  acid.  Part  of  it, 
even  to-day,  is  not  a  calculable  quantity  ;  the  circum- 
stances of  this  portion  being  not  only  chemical  in  the 
usual  sense,  but,  above  all,  biochemical.  Between  the 
two  studies  there  is  a  wide  difference :  whilst  one  can  be 
carried  out  in  the  test-tube,  the  other  can  be  only  under- 
taken with  the  co-operation  of  the  living  cell. 

The  treatment  of  gravel,  considered  in  broad  outline, 
should  have  two  objects  in  view  :  (i)  To  increase  the 
solubility  of  the  uric  acid,  and  (2)  to  decrease  the  amount 
of  its  production  if  excessive. 

(i)  In  cases  of  an  increased  tendency  to  precipitation, 
Sir  W.  Roberts  recommends  the  administration  of  alkalies 
(chiefly  at  bedtime),  the  liberal  use  of  salt*  with  food,  and 
the  free  use  of  vegetables. 

Dr.  Vaughan  Harley  has  found  piperazine  of  some 
service  in  increasing  the  solubility,  though  it  takes  no 
effect  on  the  rate  of  production  of  uric  acid ;  but  its  ad- 
ministration was  combined  with  that  of  bicarbonate  of 
potash,  and  of  iodine. 

(2)  To  reduce  the  formation  of  uric  acid,  meat  and  fish 
should  be  avoided,  as  well  as  alcohol,  in  favour  of  non- 

*  We  shall  revert  to  this  question  under  the  heading  of  Diet. 


THE  TREATMENT  OF  URIC  ACID  GRAVEL         463 

nitrogenous  supplies.  Dr.  Vaughan  Harley  draws  atten- 
tion to  the  fact  that  a  quarter  of  a  pound  to  a  pound  of 
sugar  may  be  consumed  day  by  day  without  any  increase 
taking  place  in  the  uric  acid  excreted.  There  need  not, 
therefore,  be  any  anxiety  as  to  the  use  of  sugar  from  the 
point  of  view  of  production  of  uric  acid.  According  to 
him,  those  drugs  will  be  most  serviceable  which  avail  to 
reduce  any  possible  leucocytosis.  In  this  respect  quinine 
and  arsenic  are  invaluable.  Exercise  is  also  of  great 
advantage  so  long  as  it  is  moderate. 

To  these  indications  should  be  added  the  no  less  im- 
portant one  of  free  dilution  of  the  urine.  A  milk  diet 
presents  great  advantages  in  this  respect. 

Lastly,  a  judicious  treatment  of  the  liver  on  the  lines 
which  have  been  laid  down  above  is  a  sine  qua  non  in  those 
cases  where  a  gouty  tendency  is  well  marked. 

It  is  remarkable  that  among  those  mineral  waters  which 
have  been  found  useful,  and  are  largely  recommended, 
some  are  included,  such  as  those  of  Contrexeville  and  Vittel, 
in  which  lime  is  contained  in  moderate  quantities.* 

In  the  treatment  of  gravel.  Sir  W.  Roberts  teaches  that 
the  secret  is  to  reduce  the  excessive  acidity  which,  in  an 
immense  majority  of  cases,  is  the  chief  cause,  and  for 
this  we  have  two  methods — diet  and  medication.  '  It  is 
chemically  impossible  for  uric  acid  to  be  deposited  from 
an  alkaline  urine ;  it  may  even  be  said  that  it  is  impossible 
for  uric  acid  to  be  deposited  prematurely — that  is  to  say, 
within  the  urinary  channels — from  a  neutral  or  feeble  acid 
urine.  .  .  .  We  have  in  our  hands — in  principle,  at  least — 

*  This  is  in  apparent  agreement  with  the  fact  pointed  out  by  the 
writer  (in  '  The  Climates  and  Baths  of  Great  Britain  ;  being  a  Report 
of  a  Committee  of  the  Royal  Medical  and  Chirurgical  Society  of 
London  ;'  London,  1895,  pp.  271,  273,  274)5  that  chalky  Kent  suffers 
a  less  mortality  from  calculus  than  Sussex,  Surrey,  Middlesex,  London, 
or  even  than  England  and  Wales. 


464         THE  TREATMENT  OF  URIC  ACID  GRAVEL 

the  absolute  power  of  preventing  uric  acid  gravel.'  But 
since  the  deposition  is  lasting,  constant  watchfulness  is 
requisite,  and  the  changes  in  the  secretion  need  to  be 
noticed. 

The  Acid  and  the  Alkaline  Tide. — Food,  in  connection 
with  the  treatment  of  gravel,  may  be  also  regarded  as 
medicine.  Each  of  our  meals  being  a  dose  of  alkali,  the 
greater  their  frequency,  the  greater  also  will  be  the  aggre- 
gate of  hours  of  an  alkaline  influence.  During  the  long 
interval — sometimes  as  long  as  fourteen  hours — which 
comprises  the  night's  sleep,  the  protecting  effect  of  meals 
is  lost,  and  a  dose  of  alkali  is  indicated.  We  are  re- 
minded by  Sir  W.  Roberts  that  the  quality  and  reaction 
of  the  urine  are  constantly  varying.  The  vesical  urine 
represents  in  some  cases  the  aggregate  work  of  the  kidneys 
for  many  hours  ;  but  it  is  in  the  renal  urine  that  the 
dangerous  oscillations  take  place.  The  nocturnal  urine  is 
of  scanty  flow,  of  hyperacid  reaction,  and  of  excessive  rich- 
ness in  urates.  This  is  the  urine  that  needs  correction. 
'  If  we  safeguard  the  night,  the  day  may  generally  be  left 
to  take  care  of  itself.' 

Sir  W.  Roberts  therefore  recommends  that  citrate  of 
potash,  in  doses  of  from  40  to  60  grains,  be  taken  in  3  or 
4  ounces  of  water  at  bedtime  ;  60  grains  often  render  the 
morning  urine  alkaline.  Bicarbonate  of  potassium  has 
the  same  action  ;  that  of  the  acetate  of  potassium,  though 
more  rapid,  is  less  enduring. 

As  regards  the  meals,  Sir  W.  Roberts  shows  that  'at  no 
time  during  the  waking  hours  does  the  acidity  of  the  urine 
tend  to  rise  so  high,  and  its  volume  to  fall  so  low,  as  in 
the  latter  portion  of  the  interval  between  the  first  and 
second  meal  in  the  day ;  this  interval  should  therefore  be 
abridged.'  In  connection  with  afternoon  tea,  he  refers  to 
'  an  antacid  effect  which  is  too  feeble  to  render  the  urine 


THE  TREATMENT  OF  URIC  ACID  GRAVEL         465 

actually  alkaline,  but  which  may  be  quite  sufficient  to 
depress  its  acidity  to  such  a  degree  as  shall  postpone  the 
time  of  precipitation  until  the  urine  has  escaped  from  the 
kidneys,  and  even  from  the  bladder.' 

The  Effect  of  Water  in  the  Mineral  Water  Treatment. — 
Whilst  recognising  that  with  very  great  dilution  the  pre- 
ventive effect  predominates.  Sir  W.  Roberts  observes  that, 
by  diluting  the  urine,  both  the  saline  and  the  pigmentary 
constituents  are  relatively  diminished ;  and  these  have 
been  shown  to  be  in  themselves  protective.  It  should 
also  be  borne  in  mind  that  '  in  a  couple  of  hours,  after 
even  very  free  potations,  the  surplus  water  is  entirely 
removed.  Water-drinking  has  therefore  only  a  limited 
application  in  the  treatment  of  lithiasis.' 


30 


CHAPTER  L. 

THE    TREATMENT    OF    GOUTINESS    AND    OF 
GOUTY    AFFECTIONS    (Continued). 

THE  TREATMENT  OF  THE  GOUTY  AFFECTIONS  OF 
THE  STOMACH  AND  BOWEL. 

Gastric  catarrh  is  one  of  the  most  common  manifesta- 
tions of  goutiness.  Its  acute  form  is  exceptional,  but  the 
subacute  and  chronic  varieties  are  of  common  occurrence. 
The  subacute  attack,  especially  if  sudden  and  unex- 
plained, should  remind  us  of  the  possibility  of  an  approach- 
ing articular  seizure.  In  this  case  the  treatment  would  be 
analogous  to  that  of  the  metastatic  gastric  complications, 
and  would  include  an  attempt  to  localize  the  inflammation 
in  the  foot  by  pediluvia,  poultices,  or  mustard.  Vomiting, 
if  present,  will  have  to  be  controlled  by  suitable  medica- 
tion ;  but  for  its  relief  a  total  cessation  of  food  by  the 
mouth  is  the  first  essential,  and  no  drink  should  be 
allowed,  except  perhaps  a  little  ice  to  suck.  Food  at  this 
stage  not  being  usually  required,  rectal  alimentation  need 
not  be  pushed,  but  a  nutrient  suppository  may  be  intro- 
duced three  or  four  times  a  day,  and  if  this  should  be 
rendered  necessary  by  a  continuance  of  the  vomiting, 
water  may  be  freely  supplied  by  the  bowel.  The  medi- 
cinal treatment  must  be  of  the  soothing  and  alkaline 
variety.  Effervescing  citrate  or  bicarbonate  of  potassium 
may  be  combined  with  a  little  lime-water,  and  with  small 


THE  TREATMENT  OF  GASTRIC  AFFECTIONS      467 

doses  of  hydrocyanic  acid,  and  of  the  bimeconate  of 
morphine,  which  may  prove  of  great  benefit  in  allaying 
the  irritability  of  the  stomach,  as  well  as  the  patient's 
discomfort.  If  the  case  is  placed  under  treatment  early, 
relief  will  be  rapidly  obtained,  and  in  a  day  or  two  milk 
may  be  borne  properly  diluted,  especially  if  previously 
sterilized. 

In  addition  to  the  alkalies,  a  specific  treatment  may  be 
required  in  some  gouty  cases,  and  small  doses  of  colchicum 
may  be  combined  with  the  effervescent. 

Acid  dyspepsia,  when  coupled  with  goutiness,  is  difficult 
to  cure. 

Gastric  acidity  has  been  credited  with  a  large  share  in 
the  production  of  gout.  Sydenham  held  this  view  :  *  The 
more  closely  I  have  thought  upon  gout,  the  more  have  I 
referred  it  to  indigestion,  or  to  the  impaired  concoction  of 
matters,  both  in  the  parts  and  in  the  juices  of  the  body.' 

On  the  other  hand,  the  gouty  state  itself,  and  particu- 
larly the  disturbance  of  the  liver,  may  react  upon  the 
function  of  the  stomach,  and  perpetuate  its  failure.  We 
may  mitigate  the  symptoms  by  introducing  alkalies  into 
the  stomach,  but  that  treatment  will  be  most  effectual 
which  is  directed  to  the  liver.  Colchicum  may  be  indi- 
cated in  some  cases,  and  may  conveniently  be  given  as  a 
pill ;  but  saline  purgatives  are  a  daily  essential.  We  should 
endeavour  to  influence  the  liver  by  sodium  salicylate  com- 
bined with  the  sodium  and  potassium  bicarbonates  given 
in  effervescence. 

Gastric  and  intestinal  antisepsis  is  of  primary  importance. 
For  this  we  have  a  choice  of  new  remedies,  including 
/3-naphthol,  benzo  -  naphthol,  salol,  and  resorcin.  The 
older  preparations,  such  as  sodium  hypophosphite,  sul- 
phur (in  tabloids),  creasote  (in  capsules),  and  mercurial 
preparations  (in  pill),  will  often  prove  most  effectual. 


468       THE  TREATMENT  OF  GASTRIC  AFFECTIONS 

In  aggravated  cases  a  short  course  of  nitro-muriatic 
acid  will  be  necessary  as  an  anti-fermentative  and  as  a 
hepatic  stimulant.  Or  the  patient  may  be  put  to  bed, 
and  physiological  rest  given  to  the  stomach  whilst  rectal 
alimentation  is  substituted.  The  return  to  ordinary  food 
should  be  made  so  gradual  that  the  stomach  may  learn  a 
healthier  habit  of  secretion  under  the  influence  of  purer 
blood  and  of  a  liver  free  from  congestion. 

In  this  as  in  all  gastro-intestinal  gouty  disorders,  the 
choice  of  a  suitable  health  resort  is  important.  Lecorche 
prefers,  in  most  gastric  cases,  the  mildly  calcareous  and 
sulphated  mineral  springs  of  Contrexeville,  Vittel,  Cap- 
vern,  and  Aulus,  or,  in  confirmed  and  debilitated  invalids, 
the  carbonated  calcareous  springs  of  Buxton  or  Pougues, 
or  the  mixed  carbonated  springs  of  Royat  and  St.  Nec- 
taire.  In  advanced  debility  the  muriated  waters  of  Chel- 
tenham, Homburg,  Kissingen,  and  Wiesbaden  are  to  be 
preferred. 

Intestinal  catarrh  is  often  superadded  to  gastric  catarrh, 
but  it  may  be  a  separate  manifestation  of  goutiness, 
characterized  by  alternating  periods  of  constipation  and 
of  diarrhoea.  Gouty  diarrhoea  is  sometimes  intractable. 
Sydenham  sought  relief  from  it  in  artificial  diaphoresis 
when  exercise  proved  ineffectual.  Lecorche  reports  its 
rapid  and  permanent  cure  at  Vittel  and  at  Capvern  after 
months  of  unsuccessful  treatment  by  diet  and  by  bismuth, 
opium,  and  other  remedies,  and  he  recommends  the  use 
of  Vittel  water,  or  of  Aulus  water  at  meals  to  patients 
unable  to  leave  home. 

When  constipation  predominates,  and  in  obstinate  cases, 
the  salts  or  the  waters  of  Carlsbad,  Marienbad,  or  Chel- 
tenham should  be  resorted  to. 

Gouty  Gastralgia.  —  The  immediate  treatment  of  the 
attack  must  be  devised  on  the  usual  lines.     Warmth  and 


TREATMENT  OF  GOUTY  PULMONARY  AFFECTIONS  469 

stimulation  should  be  applied  to  the  epigastrium,  with 
laudanum.  Sedatives  internally,  and  even  the  stronger 
ones,  may  be  necessary  at  first.  Lecorche  recommends 
ether  pearls,  chloral,  and  opium,  or  even  subcutaneous 
injection  of  morphine.  He  has  not  usually  found  colchi- 
cum  indispensable,  but  its  administration  may  be  tried 
with  advantage. 

It  will  be  well  in  most  cases  to  begin  with  such  simple 
remedies  as  bismuth,  sodiumi  bicarbonate  and  carbonate 
of  magnesia,  with  hyoscyamus  and  small  doses  of  hydro- 
cyanic acid,  and  with  chloric  ether.  Meanwhile  counter- 
irritation  may  be  employed.  Due  attention  will  be  paid 
to  the  state  of  the  bowels,  which  may  be  relieved  by  an 
enema  if  the  administration  of  a  purgative  should  be  un- 
desirable. 

Diet  will  need  special  consideration  in  all  gastric  affec- 
tions. 

THE  TREATMENT  OF  THE  GOUTY  PULMONARY 
AFFECTIONS. 

Inherited  goutiness  is  probably  responsible  for  the 
bronchial,  laryngeal,  and  pharyngeal  irritability  of  many 
delicate  children.  A  strong  neurotic  element  is  the  usual 
accompaniment.  A  recognition  of  the  gouty  feature  is 
essential  to  a  successful  management  of  all  these  cases. 

In  the  adult  it  is  less  likely  to  be  overlooked.  Over  and 
above  the  protective  methods,  climatic,  atmospheric,  and 
general,  even  more  necessary  here  than  in  the  ordinary 
affections,  special  treatment  is  indispensable.  Simple 
expectorants  and  inhalations  will  prove  mere  palliatives  ; 
but  the  symptoms  will  yield  readily  to  alkalies,  combined 
if  necessary  with  colchicum,  and  to  the  purgative  and 
hepatic  treatment,  the  details  of  which  we  need  not  again 
mention. 


470  TREATMENT  OF  GOUTY  PUTMONARY  AFFECTIONS 

The  weaker  mineral  waters,  and  in  preference  the  car- 
bonated and  the  muriated  waters,  such  as  those  of  Ems, 
Neuenahr,  and  Soden,  are  suitable  to  gouty  bronchitic 
ailments.  Harrogate,  Eaux  Chaudes,  Eaux  Bonnes,  and 
Cauterets  are  representatives  of  the  sulphurous  springs 
largely  recommended.  The  treatment  by  sulphur  needs, 
however,  much  discretion,  and  is  better  adapted  to  the 
catarrhal  than  to  the  spasmodic  forms.  Plethoric  cases 
will  be  benefited  by  the  milder  sulphated  waters.  Tem- 
perature, altitude,  and  surroundings  enter  largely  into  the 
question  of  selection.  A  residence  in  pine  forests,  at  a 
moderate  elevation,  is  a  valuable  addition  to  a  mineral 
course. 

Gouty  Asthma. — The  treatment  of  this  respiratory  neu- 
rosis resolves  itself  into  that  of  goutiness,  of  bronchitis, 
and  of  dyspepsia.  That  the  fits  of  gouty  asthma  are 
closely  governed  by  the  state  of  the  stomach  is  attested 
by  practical  experience ;  which  on  this  point  sets  at  rest 
any  theoretical  doubt.  The  asthmatic  seizure  is  preceded 
either  by  some  mild  transgression  in  diet  or  by  some  un- 
foreseen complication  in  the  digestive  process,  of  which 
the  sufferer  becomes  aware  after  the  event.  The  dyspeptic 
prodromata  of  the  attack  are  realized  when  it  is  too  late 
to  obviate  their  culmination  in  the  respiratory  crisis. 
Acidity  is  a  conspicuous  feature  of  the  premonitory  stage. 

These  facts  point  to  prophylaxis  as  the  major  part  of 
treatment  both  in  view  of  the  threatening  attacks,  and 
in  a  still  larger  measure  in  connection  with  the  constitu- 
tional tendency,  and  with  the  special  irritability  and  deli- 
cacy of  the  mucous  membrane  of  the  alimentary  and 
respiratory  tracts. 

Unfortunately,  the  memory  of  some  of  our  worse  physical 
sufferings  is  proverbially  short,  especially  when  they  have 
been  more  or  less  self-inflicted.     This  is  certainly  the  case 


TREATMENT  OF  GOUTY  PULMONARY  AFFECTIONS  471 

in  asthma  and  in  gout.  Painful  experiences  in  the  past  do 
not  always  avail  to  deter  from  a  relapse  into  the  causes 
which  have  led  to  the  painful  result.  The  framing  of 
strict  rules  of  diet  is  thus  of  special  importance. 

The  treatment  of  the  attack  must  be  that  of  ordinary- 
asthma.  Upon  this  we  cannot  dwell  at  length.  Among 
the  depressants  which  may  be  tried,  colchicum  may  occupy 
a  place,  but  it  is  not  of  so  much  value  in  this  as  in  some 
other  forms  of  visceral  gout.  A  rapid  purgation,  if  this 
should  not  be  contra-indicated,  may  be  of  service,  in  con- 
junction with  remedies  which  lower  arterial  tension. 

The  constitutional  gouty  factor  and  the  dyspepsia  are  to 
be  treated  during  the  intervals,  which  afford  us  an  oppor- 
tunity of  administering  such  mild  tonics  as  the  hepatic 
delicacy  or  the  idiosyncrasies  of  the  subject  may  tolerate, 
together  with  salicylates,  iodide  of  potassium,  and  iodine. 

If  the  patient  should  be  resolved  to  sacrifice  everything 
to  the  pursuit  of  health,  he  will  gain  much  from  climatic 
treatment.  This  will  have  reference,  not  only  to  the  res- 
piratory delicacy,  but  also  to  that  of  the  alimentary  tract. 
An}^  southern  station  would  fulfil  the  main  bronchial 
indication  ;  but  it  is  the  exclusive  virtue  of  some  places  to 
agree  so  well  with  asthmatics  as  almost  to  ensure  their 
complete  freedom  from  attacks. 

The  dry  bracing  air  of  altitudes,  even  during  the  winter, 
is  beneficial  to  many  of  the  younger  sufferers,  and  the 
invigorating  effect  of  a  prolonged  stay  at  St.  Moritz  or  at 
similar  stations  in  Colorado  and  other  regions  is  of  great 
and  lasting  advantage. 

When  the  neurosis  is  grafted  on  gouty  affections  of  the 
liver  and  kidney,  or  associated  with  chronic  bronchial 
catarrh,  some  of  the  milder  mineral  springs  will  have  the 
preference.  Mont  Dore  and  some  other  arseniated  waters 
enjoy  in  this  respect  a  well-deserved  reputation.     In  some 


472  TREATMENT  OF  NON-TUBERCULAR  HAEMOPTYSIS 

instances,  especially  in  old  and  debilitated  subjects,  the 
safest  course  will  be  to  trust  to  the  protecting  influence  of 
a  warm,  dry,  and  equable  climate. 

THE    TREATMENT    OF    THE    NON -TUBERCULAR    AND 

NON-CARDIAC  HEMOPTYSIS  OF  GOUTY  ELDERLY 

PERSONS. 

Sir  Andrew  Clark,*  in  describing  this  affection,  dwelt 
upon  the  importance  of  adopting  a  treatment  which, 
although  contrary  to  that  suitable  to  other  cases  of 
haemorrhage,  is,  in  these  cases,  the  only  successful  one. 
Absolute  rest,  careful  feeding,  ice  to  the  chest,  aperients, 
and  strong  astringents  frequently  repeated,  were  not  of 
the  smallest  avail  in  a  case  which  terminated  fatally  on 
the  fifth  day.  In  another  case  with  analogous  treatment, 
including  the  administration  of  lead  and  gallic  acid  and  the 
hypodermic  injection  of  ergotine,  improvement  followed 
when  the  patient's  fluid  supplies  were  restricted,  the  ice 
discontinued,  and  a  mercurial  purge  ordered,  to  be  followed 
by  an  alkaline  mixture  and  ammonia.  In  concluding  a 
review  of  other  cases  of  this  form  of  haemorrhage,  which 
he  attributed  to  minute  structural  alterations  in  the 
terminal  bloodvessels  of  the  lung  in  the  absence  of  any 
coarse  anatomical  pulmonary  or  cardiac  lesion,  Sir  Andrew 
Clark  laid  down  that  it  is  maintained  by  frequent  and 
large  doses  of  astringents,  and  by  the  amount  of  fluids 
which  are  taken  to  allay  the  thirst  thus  set  up  ;  and  that  the 
proper  treatment  consists  in  'diet  and  quiet,'  in  restrict- 
ing the  use  of  fluids,  and  in  stilling  the  cough.  Medicinally 
calomel  and  salines  are  the  chief  remedies ;  and,  for  con- 
tinuous administration,  alkalies  should  be  given  with 
iodide  of  potassium.  Sir  Andrew  Clark  also  believed  in 
the  value  of  frequently  renewed  counter-irritation. 

*  'Trans.  Med.  Soc.,'  vol.  xiii.,  i8go,  p.  9. 


TREATMENT  OF  GOUTY  CARDIAC  AFFECTIONS    473 


THE  TREATMENT  OF  THE  GOUTY  CARDIAC 
AFFECTIONS. 

Cardiac  failure  is  usually  led  up  to  by  renal  disease, 
dilatation  gradually  supervening  in  the  hypertrophied 
heart.  It  is  obvious  that  to  restore  the  hypertrophy, 
which  itself  was  a  product  of  disease,  is  more  than  we 
can  hope  to  effect.  Our  treatment  must  be  palliative  and 
protective.  The  first  indication  is  rest,  which  tends  to 
equalize  the  circulation  and  diminish  its  tension,  A 
diminution  of  the  contents  of  the  vascular  system  is  to  be 
sought  for  by  the  careful  administration  of  diuretics,  and 
by  as  much  purgation  as  is  consistent  with  the  patient's 
strength.  The  hot-air  bath  is  not  available  in  cases  of 
this  kind — at  any  rate  at  first.  Digitalis  as  a  diuretic,  as 
well  as  a  cardiac  tonic,  is  indicated  in  some  cases.  It  will 
be  well  to  seek  its  highest  cardiac  benefits  by  an  intermit- 
tent use  varied  with  the  administration  of  simpler  tonics 
and  diuretics.  Other  cardiac  tonics  may  also  be  pre- 
scribed, such  as  strophanthus,  convallaria,  caffein,  strych- 
nine, etc.  It  is  important,  as  in  all  cardiac  cases,  not  to 
prolong  the  period  of  absolute  rest  beyond  wise  limits. 
The  object  was  mainly  to  enable  the  heart  to  gradually 
reduce  its  capacity  and  the  bulk  of  its  systolic  charge. 
Unless  we  invigorate  it,  the  next  strain  thrown  upon  it 
will  soon  reproduce  the  symptoms,  since  prolonged 
muscular  inactivity,  whilst  it  wastes  the  general  muscles, 
also  impairs  in  a  definite  proportion  the  muscular  strength 
of  the  heart. 

For  this  reason  passive  exercise  should  be  resorted  to, 
preference  being  given  to  the  resistance  movements  devised 
by  Dr.  Schott ;  and  in  suitable  cases  these  may  be  com- 
bined with  the  use  of  saline  baths. 

The  intermittent  use  of  mercury  as  an  alterative  or  as 


474    TREATMENT  OF  GOUTY  CARDIAC  AFFECTIONS 

a  hepatic  stimulant  will  be  called  for  in  some  cases.  In 
other  subjects,  where  cardiac  dilatation  has  been  followed 
by  dropsy,  Baillie's  pill  may  be  cautiously  prescribed  as 
probably  the  best  combination  available. 

In  the  atheromatous  class  of  cases,  vascular  degeneracy 
predominates  over  that  of  the  kidney.  Heart  failure  is 
then  most  commonly  due  to  mechanical  circumstances 
which  cannot  be  rectified.  With  the  progressive  attenua- 
tion of  the  coronary  blood-supply  the  heart  becomes  less 
and  less  able  to  cope  with  any  extraordinary  exertion,  and 
it  is  useless  to  endeavour  to  bring  it  up  to  that  standard. 
But  in  selected  cases,  carefully  applied  passive  exercise  may 
be  of  value  in  connection  with  the  general  health,  and 
some  of  the  advantage  lost  by  cessation  from  active 
exercise  may  be  secured  for  the  liver  and  other  viscera  by 
abdominal  massage. 

Protection  from  undue  excitement  or  exertion  is  the 
great  rule  in  the  management  of  all  cases,  and  regulation 
of  diet  is  an  important  part  of  the  treatment. 

THE  TREATMENT  OF  THE  FUNCTIONAL  GOUTY 
HEART. 

As  pointed  out  by  Dr.  Mitchell  Bruce,  in  his  valuable 
paper  on  the  '  Gouty  Heart,'*  the  existence  of  goutiness 
may  be  long  unsuspected,  and  the  patient,  frequently  too 
busy  to  pay  much  attention  to  his  health,  does  not  become 
aware  of  its  irregularity  until  alarmed  by  symptoms 
directly  referable  to  the  heart ;  and  he  often  seeks  advice 
less  for  his  constitutional  than  for  his  cardiac  symptoms. 
In  dealing  with  such  a  case,  the  success  of  our  treatment 
will  depend  upon  the  correctness  of  our  diagnosis.  So 
long  as  the  gouty  factor  is  neglected,  purely  medicinal 
cardiac  remedies  will  onl}^  make  matters  worse. 
*  T/ie  Practitio7ter,  January,  1895. 


TREATMENT  OF  THE  FUNCTIONAL  GOUTY  HEART  475 

We  need  not  insist  upon  the  principles  of  constitutional 
treatment  applicable  to  this  as  well  as  to  other  cases  of 
goutiness.  The  immediate  requirement  is  relief  to  the 
cardiac  symptoms,  which  are  those  of  weakness  and 
irritability,  viz.,  inequality  to  any  sudden  strain,  angina-like 
seizures  brought  about  either  by  exertion  or  by  indiges- 
tion, giddiness  and  faintness,  insomnia  with  palpitation, 
irregular  pulse,  and  fluttering  at  the  heart. 

The  heart  being  clearly  overdriven,  the  first  requisite  is 
rest.  Rectnnbency  is,  next  to  sleep,  the  best,  and,  when 
associated  with  sleep,  the  highest,  form  of  rest  to  the 
heart ;  and  if  this  be  combined  with  a  light  and  nutritious 
diet,  which  taxes  neither  the  stomach  nor  the  liver,  much 
advantage  will  be  gained  without  delay. 

Most  patients  with  cardiac  attacks  of  some  standing  are 
dependent  for  relief  on  the  use  of  nitrite  of  amyl  and  nitro- 
glycerine. A  few  days'  rest  in  bed  on  light  food  or  exclu- 
sive milk  diet  will  put  a  stop  to  the  anginal  trouble,  and 
break  through  the  drug  habit.  A  better  opportunity  will 
arise  of  treating  thenceforth  the  cause  of  the  affection 
instead  of  its  symptoms. 

Where  goutiness  is  pronounced,  iodide  of  potassium  will 
fulfil  a  constitutional  as  well  as  a  cardiac  indication,  and 
the  hepatic  treatment  which  has  been  described  will  find 
its  application. 

Cardiac  tonics  are  not  contra-indicated,  so  long  as  the 
absence  of  high  tension  of  pulse  identifies  the  case  as  one 
of  purely  functional  angina.  Small  doses  of  digitalis  or 
strophanthus  and  strychnine  will  be  of  service  in  reducing 
the  curable  dilatation,  which  generally  underlies  the 
symptoms.  Their  use  should,  however,  be  temporary, 
and  it  loses  importance  with  the  progress  of  the  hygienic 
measures. 

The  real  cure  of  the  '  functional  gouty  heart,'  as  of  gout 


476  TREATMENT  OF  THE  FUNCTIONAL  GOUTY  HEART 

itself,  is  exercise ;  and  the  preliminary  measures  described 
are  the  early  steps  in  that  method.  Passive  movements 
may  be  begun  even  on  a  milk  diet.  When  solid  food  is 
resumed,  a  heart  free  from  valvular  defect  can  quickly  be 
trained  to  efficiency  by  Schott's  resistance  exercises.  The 
next  stage  is  active  muscular  work  in  the  open  air,  gradually 
increased  from  mere  level  walks  to  walking  uphill,  to 
golfing,  horse-exercise,  cycling,  and  even  tennis. 

On  these  lines  the  average  case  can  be  got  well  at  home, 
but  spas  may  be  visited  with  great  advantage  in  this 
country  and  abroad.  Under  careful  local  advice,  Buxton, 
Leamington,  Llandrindod,  or  even  Harrogate,  may  prove 
most  beneficial ;  and  at  Nauheim  special  treatment  will 
be  applied  on  the  basis  of  a  large  experience. 

The  happy  result  of  a  well-managed  treatment  of  the 
cardiac  neurosis  is  often  a  permanent  cure  of  the  goutiness 
which  led  to  it. 

THE  TREATMENT  OF  THE  GOUTY  NEURALGIA. 

The  severity  and  duration  of  many  neuralgise  is  due  to 
their  treatment  being  too  often  merely  symptomatic. 
Anodynes  alone  will  not  cure  them  if  they  are  due  to  a 
goutiness  which  is  overlooked  or  neglected.  Constitutional 
treatment  must  begin  with  diet;  appropriate  medication 
can  then  take  effect,  and  hygiene  will  complete  the  cure. 

The  complete  success  of  the  mineral-water  treatment  in 
cases  which  had  long  proved  rebellious  is  due  to  the  appli- 
cation of  these  broad  principles.  Balnear  treatment  is 
not,  however,  the  only  successful  method ;  moreover,  its 
application  also  requires  great  judgment.  Excellent 
results  are  to  be  obtained  without  mineral  baths,  but  only 
after  a  due  appreciation  of  the  special  requirements. 

The  goutiness  of  neuralgic  patients  cannot  be  treated  on 
general  lines.     They  are  jaded  by  prolonged  pain,  worn 


TREATMENT  OF  THE  GOUTY  NEURALGIA        477 

out  by  insomnia,  and  debilitated  by  imperfect  alimentation. 
Any  depressing  influence  can  only  add  to  the  trouble. 
Neither  excessive  purgation  nor  an  alkaline  medication  is 
admissible.  The  first  indication  is  sleep,  and  this  must  be 
secured  by  efficient  narcotic  doses.  Light  and  nourish- 
ing food  will  then  supply  a  growing  fund  of  strength,  but 
the  diet  must  be  planned  with  due  regard  to  the  gouty 
state. 

The  most  efficient  medicines  are  those  which  least  depress, 
whilst  correcting  the  constitutional  fault.  Bicarbonate 
of  sodium  is  available  in  moderate  doses,  and  may  be 
combined  with  sodium  salicylate.  The  most  useful  remedy 
is  a  combination  of  the  latter  with  iodide  of  potassium  and 
with  guaiacum,  and  the  effect  is  much  raised  by  the  addition 
of  a  sufficient  dose  (at  least  lo  minims)  of  the  tincture  of 
iodine.  The  relief  afforded  is  usually  such  as  to  be  grate- 
fully acknowledged  by  the  patient. 

This  treatment  has  been  found  markedly  beneficial  in 
obstinate  trifacial  neuralgia,  with  the  further  addition  of 
half-drachm  or  drachm  doses  of  perchloride  of  mercury 
solution.  General  massage  is  an  important  adjunct  to  the 
dietetic  and  medicinal  treatment,  which  should  be  fol- 
lowed by  the  tonic  influence  of  change  of  air. 

In  neuralgiae  of  the  large  nerves,  and  particularly  in 
sciatica,  medicinal  treatment  should  be  supplemented  by 
the  hot-air  bath,  followed  by  gentle  massage  of  the  painful 
part.  In  these  affections  the  thermal  springs  of  Bath, 
Aix-les-Bains,  Aix-la-Chapelle,  Neris,  Plombieres,  Ragatz, 
Gastein,  Wildbad,  etc.,  are  of  undoubted  service.  The 
milder  calcareous  sulphated  waters  mentioned  above  are 
also  recommended  by  Lecorche.  The  sulphurous  waters 
of  Harrogate  are  of  acknowledged  utility.  A  great  part  of 
the  benefit  derived  at  all  thermal  stations  is  doubtless  due 
to   the    combination    of  massage   with    the  heat    of  the 


478  TREATMENT  OF  REMAINING  GOUTY  AFFECTIONS 

douche.     Sulphur  also  has  a  beneficial  effect  internally, 
though  its  virtues  cannot  compare  with  those  of  iodine. 

The  treatment  of  gouty  myalgice  agrees  almost  in  every 
point  with  that  of  gouty  sciatica,  and  does  not  need 
separate  description. 

THE  TREATMENT  OF  THE  REMAINING  GOUTY 
AFFECTIONS. 

In  this  brief  sketch  of  the  treatment  of  goutiness  and  of 
its  manifestations,  many  affections  have  not  been  included. 
Various  gouty  neuroses,  and  the  gouty  disorders  of  the 
organs  of  special  sense,  of  the  larynx  and  pharynx,  and 
of  the  skin,  have  not  been  dealt  with.  In  all  of  them 
the  gouty  factor  has  to  be  regarded,  and  its  appropriate 
treatment,  which  has  been  detailed,  goes  far  towards 
a  cure  of  the  local  trouble ;  but  a  full  account  of  the 
individual  treatment  of  each  affection  would  be  a  task  out 
of  proportion  with  the  space  at  our  disposal. 


IX. 
THE  MEDICINAL  SPRINGS. 


CHAPTER  LI. 


THE  TREATMENT  OF  GOUT  AND  GOUTINESS 
BY  MINERAL  WATERS. 

THE   MEDICINAL    SPRINGS. 

The  growing  practice  of  sending  gouty  patients  to  undergo 
a  course  of  treatment  at  various  watering-places  is  en- 
couraged by  fashion,  but  it  is,  beyond  any  doubt,  founded 
upon  the  sohd  basis  of  chnical  results.  The  patients 
themselves  are  aware  of  the  benefit  they  derive,  and 
willingly  submit  to  the  discomfort  entailed. 

The  popularity  and  efficacy  of  this  form  of  treatment, 
and  the  great  variety  in  the  composition  of  the  different 
waters,  render  indispensable  a  cursory  review  of  the  whole 
subject,  and  some  account  of  the  various  springs  which  are 
suitable  to  the  several  phases  and  kinds  of  the  gouty 
affections. 

The  General  Characters  and  Chief  Varieties  of  Medicinal 
Springs. — In  gouty  arthritis  the  most  obvious  indication  is 
the  external  and  local  application  of  the  treatment ;  in  visceral 
gout  and  in  goutiness  the  internal  use  of  the  waters  is  the 
most   essential.     On   the  other~  hand,   the  constitutional 


48o  THE  MEDICINAL  SPRINGS 

aspect  of  arthritic  gout  demands  internal  medication,  and 
visceral  gout  and  goutiness  are  also  largely  dependent  for 
their  improvement  upon  the  effect  of  the  baths  upon  the 
general  cutaneous  surface.  It  follows  that  the  best,  it 
might  almost  be  said  the  only,  springs  available  are  those 
suited  for  external  as  well  as  for  internal  use ;  and  since 
cold  applications  are  eminently  contra-indicated  in  gout, 
our  choice  is  limited  to  the  thermal  springs.  An  apprecia- 
tion of  this  fact  has  led  to  the  artificial  heating,  for  external 
use,  of  various  waters,  the  medicinal  value  of  which  is 
great,  but  which  by  reason  of  their  low  temperature  would 
not  have  been  available  for  the  adequate  treatment  of 
gout.  The  most  striking  instance  in  this  country  is  that 
of  Harrogate. 

Again,  a  sufficient  heat  being,  for  external  application, 
far  more  important  than  the  solids  contained  in  solution, 
whilst  pure  water  imbibed  in  sufficient  amount  is  a  valuable 
therapeutic  agent,  various  neutral  or  indifferent  springs 
containing  relatively  small  quantities  of  solids  are  turned 
to  account  by  reason  of  their  thermality.  These  simple 
waters  we  shall  include  in  Group  /.*  Bath,  Buxton,  Wild- 
bad,  Gastein,  Ragatz-Pfafers,  Schlangenbad,  and  many 
other  '  Wildbader,'  belong  to  this  group.  To  this  class 
also  belongs  Hammam  RThra,  a  mildly  saline  hot-water 
spring  (114°  Fahr.),  situated  about  75  miles  from  Algiers, 
at  an  elevation  of  2,000  feet  above  the  sea-level,  in  a  site 
unexcelled  in  its  beauty  and  salubrity. 

The  most  important  mineral  constituents  of  the  active 
springs  may  be  classified  as  the  alkaline  carbonates  and  the 
earthy  carbonates ;  the  alkaline  sulphates  and  the  earthy 
sulphates  ;  the  chlorides  of  the  alkalies  (but  chiefly  of 
sodium)  and  of  the  earths  ;  the  sulphides  and  sulphuretted 

*  The  grouping  which  is  here  suggested  is  slightly  altered  from 
Dr.  Bumey  Yeo's  excellent  classification  of  the  mineral  springs. 


THE  MEDICINAL  SPRINGS 


hydrogen  ;  and  the  smah  quantities  of  iodides,  bromides 
(Woodhah  Spa),  and  arseniates,  and  of  the  salts  oi  lithium, 
which  occur  in  various  springs.  Lastly,  free  carbonic  acid 
is  given  off  by  many  of  them. 

For  convenience  we  refer  to  the  various  waters  as  car- 
bonated, sulphated,  muriated,  chalybeate  (or  containing  iron), 
and  sulphurous.  None  of  them,  however,  are  pure  solutions 
of  any  of  these  substances  ;  these  abbreviated  expressions 
merely  imply  a  preponderance  of  the  constituents  to  which 
they  refer.  All  analyses  show  a  more  or  less  mixed  com- 
position of  the  waters. 

Group  II.  contains  the  least  complex  combinations — 
v\z.,  sodium  chloride  in  abundance,  and  traces  only  of  the 
other  alkaline  salts,  but  often  much  carbonic  acid  gas, 
which  usually  keeps  some  carbonate  of  lime  in  solution. 
(Cold  or  tepid,  gaseous  springs :  Homburg,  Kissingen, 
Leamington;  hot, non-gaseous:  Wiesbaden,  Baden-Baden; 
hot,  gaseous:  Nauheim,  Rehme,  Bourbonne-les-Bains,  etc.) 

Brine  baths  (Droitwich,  Kreuznach,  Ischl,  Rheinfelden, 
Aussee,  Reichenhall,  Harzburg,  and  many  others)  are  not 
in  general  as  suitable  in  gout  as  in  many  other  affections, 
although  the  local  effect  on  stiffened  articulations,  or  in 
chronic  sciatica,  may  be  beneficial. 

The  alkaline  springs  contain  sodium  bicarbonate  largel}', 
with  an  excess  of  carbonic  acid  gas,  and  only  unimportant 
percentages  of  the  other  alkaline  carbonates.  Other  salts 
may  be  present  in  insignificant  amounts.  The  springs 
may  then  be  described  as  simple  alkaline,  forming  our 
Group  III. 

The  strongest  alkaline  springs,-  those  of  Vals  and  Vichy 
(5  to  6  pro  mille),  do  not  contain  sufficient  carbonate  of 
lime  (0*46  to  o"57  pro  mille)  to  counteract  their  efficiency 
in  vesical  and  prostatic  catarrhs,  and  in  biliary  and  urinary 
concretions  ;  but  their  chief  use  is  in  gout,  for  which  some 

31 


THE  MEDICINAL  SPRINGS 


of  these  springs  possess  the  desirable  temperature.  Neuen- 
ahr  (famed  for  diabetes,  a  much  weaker  alkahne  spring) 
is  also  thermal,  a  property  lacked  by  the  other  German 
alkaline  springs,  which  include  Fachingen,  Bilin,  Salz- 
brunn,  and  Assmannshausen,  The  lithmm  bicarbonate 
reaches  in  the  last-named  its  highest  recorded  proportion 
(0*027  pro  mille) ;  but  the  Bonifaciusbrunnen  of  Sakschlirf 
(belonging  to  Group  II.)  contains  the  highest  known  per- 
centage of  lithium  as  a  chloride  (0*218  pro  mille),  with 
io"2  pro  mille  of  sodium  chloride. 

Group  IV.  is  formed  by  the  alkaline  miiriated  springs,  of 
which  Ems  is  the  type,  containing  with  sodium  chloride 
varying  amounts  of  sodium  bicarbonate  ;  they  are  well 
adapted  for  the  treatment  of  respiratory  and  gastric 
catarrhs.  The  Royat  and  La  Bourboule  waters  present 
the  advantage  of  a  little  arsenic  in  addition  to  traces  of 
lithium. 

Group  v.,  that  of  the  alkaline  sulphated  springs,  occupies 
a  large  place  in  the  treatment  of  gout  and  of  goutiness. 
Combining  the  neutralizing  and  alterative  properties  of 
sodium  bicarbonate  with  the  laxative  and  eliminative 
action  of  the  sulphate  of  that  metal,  their  power  for  good 
is  great,  but  it  calls  for  a  corresponding  amount  of  discre- 
tion in  its  application.  The  members  of  this  group  are 
not  numerous,  but  they  differ  much  in  their  strength. 
Carlsbad,  with  its  sixteen  springs,  varying  in  temperature 
from  95°  to  160°  Fahr.  (Sprudel),  heads  the  list,  and  is 
practically  unrivalled.  Brides-les-Bains,  which  has  been 
described  as  '  the  French  Carlsbad,'  is  less  searching,  but 
applicable  to  the  same  class  of  cases.  Maricnbad  enjoys  a 
wide  reputation  for  the  treatment  of  obesity.  Its  waters 
are  not  naturally  thermal,  ranging  from  g°  to  11°  C, 
but  their  internal  effect  is  similar  to  that  of  the  Carlsbad 
springs.  It  enjoys  a  greater  elevation  (628  metres  above 
the  sea-level),  and  a  bracing  climate. 


THE  MEDICINAL  SPRINGS  483 

Tarasp,  in  the  Lower  Engadine,  is  at  a  much  greater 
elevation  (1,200  to  1,270  metres  above  the  sea-level).  The 
Lucius  spring  contains  147  total  solids  in  1,000  parts 
(bicarbonate  of  sodium,  4*9 ;  chloride  of  sodium,  3"6  ; 
sodium  sulphate,  2"i  ;  and  carbonic  acid  gas,  2,380  c.cm.). 
Numerous  chalybeate  springs  occur  in  the  vicinity. 

Groiip  VI. — The  alkaline  earthy  springs  contain  chiefly 
lime  and  magnesia  in  the  shape  of  sulphates  and  car- 
bonates, with  small  and  varying  amounts  of  other  metallic 
salts,  usually  in  association  with  free  nitrogen  and  carbonic 
acid  gas.  They  have  been  found  of  use  in  catarrhal  states 
of  the  mucous  membranes,  and  particularly  of  the  urinary 
passages,  and  prostate,  and  in  renal  and  vesical  concre- 
tions. 

Their  suitability  in  gouty  affections  is  to  be  gauged  by 
the  relative  amount  of  sodium  and  magnesium  sulphate 
which  some  of  them  contain,  in  addition  to  the  carbonates. 
Contrexeville,  Vittel,  Martigny,  Capvern,  Evian,  Wildun- 
gen,  and  Driburg  are  the  best  known  representatives  of 
this  group.  Cheltenham  waters  contain  a  larger  proportion 
of  sodium  and  magnesium  sulphates  than  any  of  these. 

Group  VII.  is  one  of  the  most  important,  including  the 
hot  and  the  cold  sulphur  springs:  Aix-les-Bains  and  Aix-la- 
Chapelle,  Baden  near  Vienna,  Baden  near  Zurich,  Schintz- 
nach  (33°  C),  Helouan,  near  Cairo  (32°  C.)  ;  Uriage  ; 
Allevard;  St.  Honore;  and  in  the  Pyrenees  Cauterets,  Eaux 
Bonnes,  Eaux  Chaudes,  Bareges,  Bagneres  de  Luchon, 
St.  Sauveur,  and  Amelie-les-Bains  ;  and  lastly  Panticosa 
in  Spain,  and  Mehadia  in  Hungary,  are  all  thermal 
springs. 

Eilsen,  Nenndorf,  Meinberg ;  Schimberg,  Gurnigel  and 
Heustrich,  at  moderate  elevations  in  the  Swiss  Alps  ; 
Weilbach,  intheTaunus  range  near  Wiesbaden  ;  Enghien, 
near  Paris,  and  Challes,  near  Aix-les-Bains,  are  cool 
sulphur  springs. 


484      THE  MINERAL  SPRINGS  OF  NORTH  AMERICA 

To  the  same  class  belong,  in  this  country,  Harrogate, 
Dinsdale  -  on -Tees,  Moffat,  Strathpeffer,  Llandrindod, 
Builth  ;  and  in  Ireland,  Lisdoonvarna. 

Group  VIII. — The  chalybeate  springs,  according  to  Dr. 
Hermann  Weber's  classification,  maybe:  (i)  comparatively 
pure,  with  only  feeble  quantities  of  any  other  substances 
in  solution,  as  those  of  Tunbridge  Wells,  of  one  of  the 
springs  at  Harrogate,  of  Flitwick,  Spa,  Schwalbach,  and 
others  ;  (2)  of  mixed  composition,  either  containing  car- 
bonates and  sulphates  of  sodium,  calcium,  and  magnesium 
and  common  salt,  as  those  of  Orezza,  Pyrmont,  Driburg, 
St.  Moritz,  Bussang  ;  or  containing  sulphate  of  iron,  as  the 
waters  of  Flitwick,  Muskau,  Parad,  Alexisbad,  and  Ratzes. 
Those  of  Roncegno  and  Levico,  in  the  Austrian  Tyrol, 
are  powerful,  and  contain  sulphate  of  iron  in  conjunction 
with  arsenic  (H.  Weber). 

THE  MINERAL  SPRINGS  OF  THE  NORTH  AMERICAN 
CONTINENT. 

The  following  particulars  are  supplied  by  Lyman  :* 

The  thermal  waters  of  Arkansas  hot  springs  contain 
little  earthy  or  saline  matter.  The  hot  springs  in  South 
Dakota  are  rich  in  chlorides  and  other  salts. 

In  the  United  States,  purely  alkaline  waters  are  few 
and  of  low  strength ;  e.g.,  Bladen  springs  in  Alabama,  the 
Congress  and  the  Seltzer  springs  in  California,  the  latter 
containing  as  much  as  10  grains  in  the  pint  of  magnesium 
carbonate  (H.  Weber),  the  St.  Louis  springs  in  Michigan, 
and  the  Sheldon  springs  in  Vermont,  are  the  best  known. 

The  Canadian  springs  of  St.  Katharine  and  Caledonia, 
the  wells  at  St.  Clair,  at  Mount  Clements,  and  others  in 

*  '  Twentieth  Century  Practice  :  an  International  Encyclopaedia  of 
Modern  Medical  Science,'  etc.  Edited  by  T.  L.  Stedman,  M.D., 
New  York  City,  vol.  ii.,  "'  Nutritive  Disorders,'  1895. 


THE  MINERAL  SPRINGS  OF  NORTH  AMERICA      485 

Michigan,  the  Saratoga  springs  in  New  York,  and  the 
Crab  Orchard  springs  in  Kentucky,  represent  the  sul- 
phated  sahne  group.  To  these  may  be  added  the  Estrill 
springs,  the  Bedford  springs,  and  the  Midland  well  (H. 
Weber). 

The  miiriated  saline  group  includes  the  Glenwood  springs 
in  Colorado,  the  St.  Catherine  wells,  the  Michigan  Con- 
gress spring,  the  Spring  Lake  well,  the  Fruit  Port  well, 
the  Saratoga  springs,  and  the  Ballston  Spa  (H.  Weber). 

The  feebly  mineralized  waters  of  Poland,  in  Maine,  and 
of  Wakusha,  in  Wisconsin,  approximate  those  of  Con- 
trex6ville  and  Vittel,  and  are  suitable  for  cases  of  diabetes 
and  of  renal,  vesical,  or  biliary  concretions. 

According  to  Dr.  H.  Weber,  the  mixed  chalybeate  springs 
in  North  America  are  :  the  Bailey  springs,  the  Stafford 
springs,  the  Greencastle  springs,  the  Estrill  springs,  the 
Schooley  Mountain  springs,  the  Montvale  springs,  and  the 
Rawley  springs. 

The  sulphate  of  iron  springs  are  :  The  Oak  Orchard  acid 
springs,  the  Bath  alum  springs,  and  the  Variety  springs. 

Lyman  gives  an  interesting  quotation  from  Beaumont 
Small's*  classification  of  the  mineral  springs  of  the  United 
States  :  Small  refers  to  the  waters  found  in  the  Western 
mountainous  district,  extending  from  the  Pacific  coast 
almost  to  the  Mississippi  River,  as  '  chiefly  alkaline  springs 
containing  a  few  grains  of  the  purgative  salines,  generally  of 
a  high  temperature  and  strongly  sulphurated.  Thermal 
saline  springs,  with  or  without  sulphuretted  hydrogen,  also 
occur,  such  as  the  Utah  and  Kalistoga  springs. 

'  In  the  East  the  highly-carbonated  and  alkaline-saline 
springs  are  the  most  common.  The  only  thermal  springs 
are  in  Virginia  and  the  South.  These  are  only  slightly 
sulphurated,  and  almost  imperceptibly  alkaline. 

*  '  Reference  Handbook  of  the  Medical  Sciences,'  vol.  Iv.,  p.  694. 


486  THE  HOT  SPRINGS  OF  NEW  ZEALAND 

'  In  the  great  Palseo^oic  Basin,  which  formed  the  bed  of 
the  early  sea,  we  only  find  the  waters  rich  in  salines. 
Those  containing  chlorides  are  to  be  found  everywhere, 
but  such  as  contain  the  purgative  sulphates  are  chiefly 
confined  to  certain  districts,  as  in  Kentucky,  Michigan, 
and  western  New  York.  In  these  the  active  salt  is 
sulphate  of  magnesium.  In  this  they  differ  from  the 
purgative  waters  of  the  West,  which  owe  their  properties 
to  sulphate  of  soda. 

'  In  Canada  the  springs  are  chiefly  saline  and  alkaline- 
saline  ;  a  large  proportion  are  ferrated  and  sulphurated.' 

THE  HOT  SPRINGS  OF  NEW  ZEALAND. 

The  writer  is  indebted  to  Dr.  W.  E.  Collins,  of  Welling- 
ton, for  valuable  information  concerning  the  therapeutic 
uses  of  the  celebrated  thermal  springs  of  the  Hot  Lake 
district  in  the  North  Island,  which  covers  an  area  fifty 
miles  in  length  and  twenty  miles  in  width,  and  in  which 
Rotorua  '  with  its  numerous  hot  springs,  its  geysers  and 
mud  volcanoes,  its  green,  yellow,  and  blue  lakes,  and  its 
terraces  of  silica,'  is  the  centre  of  attraction. 

The  Government  have  established  a  hospital  for  the 
balnear  treatment  of  patients. 

'  The  mineral  waters  of  this  district  are  classified  from 
analyses  made  in  the  Colonial  Laboratory  under  the 
following  groups  : 

1.  Saline,  containing  NaCl. 

2.  Alkaline,  containing  carbonates  and   bicarbonates 

of  soda  and  potash. 

3.  Alkaline  silicious,  containing  much  silicic  acid,  but 

changing  rapidly  on  exposure  to  the  atmosphere, 
and  becoming  alkaline  ;  these  on  cooling  deposit 
silica,  and  so  form  the  terraces. 


ANALYSIS  OF  THE  PURIRI  WATER  487 

4.  Sulphurous,  containing  sulphuretted  hydrogen  and 

sulphurous  acid. 

5.  Acid,  containing  an  excess  of  mineral  acids,  such 

as  hydrochloric  and  sulphuric  acids. 

6.  Muddy    waters  ;    mineral  waters    are   here  mixed 

with  a  pasty  clay.     It  is  an  acid  mixture,  rich  in 
sulphuretted  h3'drogen.' 

'  The  chief  medicinal  baths  are  : 

1.  The  Priest's  Bath,  Te  Pupunitanga. 

2.  Madame  Rachel's  Bath,  Whangapipiro,  cooled  to 

any  temperature. 

3.  The  Painkiller  Bath. 

4.  The  Coffee-pot  Bath. 

5.  Hinemaru  or  Stonewall  Jackson's  Bath. 

6.  The  Blue  Bath,  a  warm  swimming-bath. 

7.  Cameron's  Bath.' 

The  following  analysis  of  the  cold  effervescing  water  of 
Puriri  (about  10  miles  distant  from  Grahamstown),  shows 
that  it  is  analogous  to  the  waters  of  Fachingen  and  Ems. 

THE  PURIRI  WATER. 


Grains  per  Gallon. 

Chloride  of  sodium 

. 

21-938 

Iodide  of  magnesium 

- 

Traces 

Sulphate  of  soda 

■ 

0-940 

„           potash 

• 

4'938 

Carbonate  of  iron 

. 

Traces 

Bicarbonate  of  lime 

. 

28-506 

„              magnesia 

■ 

25-625 

„              soda 

- 

452-393 

„              lithia 

. 

Traces 

Silica       -             -             -             - 

. 

2-772 

Phosphoric  acid  - 

-  Not  determined 

537-112 


488  THE  PURIRI  WATER 

Dr.  Collins  writes  :  '  I  have  found  the  Puriri  water 
most  useful  in  gout.  I  know  of  one  instance  where  a 
gentleman  had  had  for  many  years  at  least  one,  often  two, 
attacks  of  gout  during  the  course  of  each  year,  and  was 
thereby  incapacitated  from  work  for  longer  or  shorter 
periods  of  time.  He  had  had  all  kinds  of  treatment  from 
many  different  practitioners,  but  for  some  years  now  he 
has  not  suffered  at  all,  and  he  attributes  his  freedom  from 
gout  during  that  time  to  the  fact  that  he  drinks  his  water 
daily;  the  only  other  treatment  he  adopts  is  that  of  having 
a  Turkish  bath  once  or  twice  a  week.' 

To  the  favoured  few  to  whom  time  and  distance  are  no 
obstacle  in  the  pursuit  of  health,  the  New  Zealand  springs 
might  offer  the  great  advantage  of  a  thorough  course  of 
thermal  treatment  during  our  winter  months,  when  this  is 
not  attainable  under  favourable  climatic  conditions  in  the 
Northern  Hemisphere. 


CHAPTER  LII. 

THE    USES    AND    THE    SELECTION    OF 
MEDICINAL  SPRINGS. 

THE     SULPHATED     WATERS. 

THE  GENERAL  THERAPEUTICAL  ADVANTAGES  OF 

SPAS. 

Theoretically  the  choice  is  perplexing,  but  happily  our 
practical  selection  is  guided  by  the  results.  We  are  struck 
by  the  large  measure  of  success  reported  almost  uniformly 
from  the  various  baths,  the  effects  of  which,  as  gauged  by 
analysis,  should  present  the  strongest  contrast.  Allowance 
should  be  made  for  an  influence  of  the  genms  loci,  which 
turns  patients  into  advocates  for  the  resort  with  which 
they  are  identified ;  yet  we  cannot  avoid  the  conclusion 
that  solid  advantages  belong  in  common  to  the  majority  of 
health  resorts,  and  that  their  health  value  is  not  to  be 
reckoned  in  grains  of  salt  per  gallon  of  the  mineral  waters, 
nor  according  to  any  chemical  formulae. 

Almost  every  variety  of  mineral  water  can  now  be 
obtained  and  used  by  patients  at  their  own  homes  ;  but 
the  relative  inefficiency  of  this  form  of  treatment  shows 
that  the  benefit  derived  at  watering-places  is  not  alto- 
gether due  to  the  daily  consumption  of  so  many  glasses  of 
this  or  of  that  mineral  water.  Complete  rest  from  the 
fatigue  and  anxieties  of  business,  and  from  the  routine  of 


490  GENERAL  ADVANTAGES  OF  SPAS 

home-life,  the  novelty  of  the  surroundings,  the  change  of 
air  and  of  scenery,  the  longer  hours  spent  in  the  open  air, 
the  altered  and  specially-selected  dietary,  the  increased 
amount  of  exercise,  the  regular  and  early  hours — these  are 
some  of  the  advantages  which  are  common  to  all  resorts, 
but  which  go  to  establish  the  individual  reputation  of 
each. 

There  is  also  the  exhilarating  effect  of  the  amusemients 
now  provided  at  most  Continental  resorts,  and  the  im- 
portance of  which  is  beginning  to  be  appreciated  at  our 
own  spas. 

Medical  reasons  also  explain  the  prevailing  average  of 
favourable  results.  Mutual  criticism  has  advanced  the 
local  physicians'  knowledge  of  the  shortcomings  of  each 
mineral  spring,  as  well  as  of  its  virtues,  and  has  led  more 
and  more  to  the  avoidance  or  to  the  correction  of  the 
former.  Much  improvement  has  resulted  also  from  a 
wider  appreciation  of  the  great  principles  of  balnear 
treatment  :  their  application  is  now  more  varied,  accord- 
ing to  requirements,  and  more  judiciously  adapted  to  each 
individual  case.  Lastly,  another  element  in  producing 
this  uniformity  has  been  the  efficiency  and  the  more  and 
more  widespread  adoption  of  the  Aix  method.  So  im- 
portant are  its  results  in  gout  that  they  probably  in  great 
measure  dwarf  chemical  and  therapeutical  differences, 
which  otherwise  might  have  been  more  prominent. 

Summer  is  the  best,  and  at  some  stations  the  onh', 
season  for  a  visit  to  the  springs.  In  winter  some  of  the 
most  efficacious  spas  are  deserted,  and  at  those  which 
remain  open  in  Great  Britain  and  on  the  Continent  the 
atmospheric  conditions  are  not  those  to  be  desired  for  the 
most  successful  management  of  gout.  This  circumstance 
gives  special  value  to  the  thermal  springs  of  subtropical 
zones,  and  to  those  of  the  Antipodes. 


GENERAL  INDICATIONS  49 1 

THE  GENERAL  INDICATIONS. 

The  various  types  of  gouty  affections  give  different  in- 
dications as  to  the  internal  or  external  use  of  the  waters. 

1.  A  separate  class  is  that  of  the  late  results  of 
chronic  gouty  arthritis,  the  thickened  and  stiffened  articular 
structures.  For  these  local  treatment  is  the  essential, 
though  not  the  only,  requisite. 

2.  In  the  other  form  of  advanced  local  changes,  the 
tophaceous,  the  internal  treatment  assumes  greater  import- 
ance by  the  side  of  the  local. 

3.  Cases  of  relapsing  acute  gout,  of  a  sthenic  kind,  need 
a  full  measure  of  constitutional  treatment. 

4.  The  milder  cases  of  liability  to  slight  and  infrequent 
attacks  of  acute  arthritis  need  not  be  separated  from  those 
of  general  goutiness  in  which  articular  manifestations  are  ill 
developed.  In  all  these,  constitutional  treatment  is  needed, 
and  should  be  aided  by  balnear  treatment.  In  inherited 
goutiness  prophylaxis  is  the  early  indication. 

5.  Gouty  glycosuria  and  renal  disease  are  sharply  defined 
from  other  groups.  Their  treatment  is  largely  dietetic  as 
well  as  constitutional. 

6.  The  remaining  group,  that  of  the  abarticular  visceral 
or  peripheral  manifestations  of  goutiness,  includes  :  {a)  The 
affections  of  the  skin  and  its  appendages  ;  (b)  the  affections 
of  the  mucous  membranes,  respiratory,  gastric,  and  intes- 
tinal ;  (c)  the  affections  of  the  liver  and  biliary  system  ; 
{d)  the  renal  and  vesical  affections.  Internal  treatment  is 
needed  in  all,  and  external  treatment  is  of  use,  but  the 
indications  vary  with  the  structures  involved. 

The  skilled  and  cautious  external  application  of  the 
thermal  waters  is  beneficial  in  almost  all  cases  of  chronic 
articular  gout ;  and  in  the  majority  of  the  visceral  forms  of 
g-outiness  their  value  is  great.    The  contra-indications  are : 


492  GENERAL  INDICATIONS 

acute  cutaneous  complications,  cardio-vascular  degenera- 
tions, and  advanced  age.  Safest  and  most  generally  suc- 
cessful are  the  thermal  baths,  such  as  those  at  Bath, 
Buxton,  Aix-les-Bains,  and  many  others,  which  are  only 
slightly  mineralized.  A  high  percentage  of  salt  or  of 
sulphur  may  prove  too  exciting  in  some  cases.  Brine 
baths  are  for  this  reason  less  indicated  in  gout  than  in 
rheumatism,  and  in  gouty  skin  affections  they  are  contra- 
indicated. 

Internal  treatment  is  a  much  more  difficult  question.  A 
few  indications  are  simple  and  direct :  Iron  and  arsenic  for 
anaemia;  sulphur  for  some  chronic  gouty  affections  of  the 
skin  ;  sulphur  for  catarrhal  affections  of  the  respiratory, 
gastric,  and  intestinal  mucous  membranes  ;  and,  again, 
sulphur  for  hepatic  torpidity.  Beyond  this,  opinions  are 
at  variance  and  conclusions  are  doubtful.  For  instance, 
the  desirability  of  treating  a  nervous  case  by  the  arsenical 
constituents  of  a  given  spring  should  not  close  our  eyes  to 
the  disadvantages  which  may  be  associated  with  this  gain, 
nor  to  preponderating  advantages  which  might  elsewhere 
be  secured.  After  all,  a  minute  quantity  of  arsenic 
added  to  any  mineral  water  might  fulfil  this  relatively 
insignificant  part  of  the  mineral  cure.  To  the  arbitrary 
modification  of  mineral  waters  deficient  in  some  desired 
constituent,  we  shall  presently  refer. 

More  debatable  are  the  indications  for  the  alkaline,  the 
sulphated,  the  muriated,  and  the  calcareous  waters.  It  is 
easy  to  lay  down  hard  and  fast  lines  :  the  alkaline  car- 
bonates should  suit  all  cases  of  excessive  acidity ;  the 
alkaline  and  magnesian  sulphates  are  the  proper  treatment 
for  hepatic  engorgement  and  constipation ;  a  similar 
influence,  without  so  much  purgative  effect,  should  be 
found  in  the  muriated  springs ;  the  milder  calcareous 
waters  should  allay  the  irritability  and  clear  the  obstruc- 


THE  SULPHATED  WATERS  493 

tions  of  catarrhs,  and  particularly  those  of  the  alimentary 
canal.  Matters,  however,  are  much  complicated  by  the 
presence  in  most  springs  of  a  variety  of  salts,  sometimes 
almost  contradictory  in  their  action,  and  we  are  compelled 
to  inquire  more  closely  into  the  effects  of  individual  spas. 

THE  SULPHATED   WATERS. 

We  may  deal  first  with  the  relatively  simple  question  as 
to  the  use  of  sulphated  waters,  such  as  those  of  Carlsbad, 
Marienbad,  Brides-les-Bains,  etc.  There  is  little  doubt 
that  these  are  in  principle  applicable  to  a  large  class  of 
cases  ;  the  question  as  to  their  use  is  rather  one  of  degree 
and  of  adjustment.  It  is  sometimes  alleged  that  their  effect 
is  depressing.  This,  however,  is  not  borne  out  by  the 
testimony  of  experienced  physicians ;  it  may  have  arisen  in 
connection  with  their  injudicious  use  by  the  patients. 

Idiosyncrasy  should  be  borne  in  mind  in  this  as  in  all 
other  matters  relating  to  gout.  In  some  cases  the  ques- 
tion may  lie  between  the  relative  suitability  of  the  sulphatic 
treatment  and  that  of  the  derivative  and  laxative  treat- 
ment obtainable  at  the  sulphurous  springs,  and  at  some  of 
the  calcareous  springs  respectively. 

The  value  of  the  muriated  and  of  the  calcareous  springs 
has  often  been  questioned ;  and  a  yet  more  serious  question 
relates  to  the  action  of  the  sodic  springs  in  gout.  Sodium 
being  the  chief  constituent  of  all  alkaline  and  of  all 
muriated  springs,  this  doubt  concerns  a  very  large  propor- 
tion of  the  most  highly  reputed  mineral  waters.  To  these 
more  disputed  points  in  practical  balneology  we  shall  now 
sfive  our  attention. 


CHAPTER  LIII. 

THE    USES    AND    SELECTION    OF    MEDICINAL 
SPRINGS  {Continued). 

THE  CALCAREOUS  WATERS. 

Lime  as  sulphate  or  carbonate  is  a  widespread  constituent 
of  drinking-water.  Hard  water  has  sometimes  been  ac- 
cused* of  producing  gout  or  of  favouring  its  manifesta- 
tions. In  the  tables  of  mortality  collated  by  the  writer  in 
the  Climatological  Report  of  a  Committee  of  the  Royal 
Medical  and  Chirurgical  Society,!  it  is  shown  that,  in  spite 
of  the  calcareous  nature  of  its  water,  Kent  suffers  less 
severely  from  gout  than  Sussex,  and  much  less  severely 
than  Surrey  or  Middlesex,  although  its  mortality  from 
gout  is  greater  than  that  recorded  in  London,  and  much 
greater  than  that  belonging  to  England  and  Wales.  It  is 
noteworthy  that,  in  their  mortality  from  rheumatism  also, 
Kent,  Sussex,  and  Surrey  preserve  the  same  order,  and 
that  in  both  cases  Kent  yields  almost  the  same  returns  as 
London.  Middlesex,  which  suffers  more  than  the  three 
other  counties  in  connection  with  gout,  suffers  less  than 
any  of  them  in  connection  with  rheumatism.  The  figures 
extracted  from  the  Registrar-General's  annual  report  for 
1 89 1  are  as  follows  : 

*  Cf.  Duckworth  {loc.  cit.,  pp.  361,  412).  f  Loc.  cit.,  p.  272. 


THE  CALCAREOUS  WATERS 


495 


Mortality  per 

Million  Persons  Living. 

Gou/. 

Rheiimatis7n. 

England  and  Wales  - 

22 

•45 

Middlesex  -          27-55 

London 

36 

^4 

London 

28-42 

Kent  -         -          38-32 

Kent            -          28-43 

Sussex        -          5574 

England  and  Wales    - 

36-69 

Surrey        -          60-85 

Sussex         -          3776 

Middlesex-          63-72 

Cali:n 

Surrey         -          43'47 
•Ins. 

Kent 

-     7-41 

England  and  Wales 

-     814 

Sussex 

-         -     8-99 

Surrey 

- 

-    10-43 

Middlesex 

- 

-   12-05 

London    - 

- 

-   14-21 

The  last  table  shows  a  perceptibly  lower  rate  of  mor- 
tality from  calculus  in  Kent  as  compared  with  England 
and  Wales,  and  especially  with  Sussex,  Surrey,  Middlesex, 
and  London.  This  remarkable  fact  almost  disposes  of  the 
notion  that  calcareous  water  favours  the  formation  of 
stone.  Indeed,  lime-water  and  the  salts  of  lime  were 
formerly  prescribed  as  specifics  not  only  for  stone,  but  for 
gout ;  and  at  the  present  time  the  waters  of  Contrexeville 
and  Vittel,  in  spite  of  the  salts  of  lime  which  they  contain, 
are  recommended  for  urinary  concretions  almost  in  prefer- 
ence to  those  of  Vichy,  which  contain  relatively  less 
calcium. 

The  behaviour  of  the  salts  of  lime  towards  the  tissues  is 
still  incompletely  understood.  In  some  diseases,  such  as 
rickets  and  osteo-malacia,  calcium  is  imperfectly  fixed  by 
tissues  in  spite  of  an  abundant  supply  ;  whilst  in  atheroma 
and  in  other  calcifying  diseases  they  attract  and  detain  it, 
although  no  excess  of  lime  may  have  been  ingested.  The 
fault  seems  to  lie  rather  with  the  tissues  than  with  the 


496  THE  CALCAREOUS   WATERS 

suppl}',  which,  with  an  average  dietary,  is  more  than" 
sufficient  for  the  needs  of  the  economy.  In  short,  there  is 
always  a  surplus  passing  out  through  the  kidneys  and 
bowel ;  and  so  long  as  this  habitual  surplus  is  not  drawn 
upon  for  the  pathological  purpose  of  deposition,  no  harm 
will  come  of  its  being  increased  by  the  ingestion  of  cal- 
careous waters,  provided  the  urinary  and  alvine  excretion 
is  promoted  rather  than  checked  by  them,  and  provided 
also  the  percentage  of  lime  is  not  such  as  to  act  as  an 
irritant  to  the  mucous  membrane  of  the  stomach. 

The  belief  in  a  solvent  power  of  carbonated  calcareous 
waters  for  uric  acid  has  received  some  confirmation  from 
the  comparative  observations  of  Fiirst*'  on  the  behaviour 
of  urines  secreted  after  drinking  the  various  mineral 
waters.  The  method  employed,  which  is  open  to  obvious 
objections,  consisted  in  adding  (under  the  same  experi- 
mental conditions)  to  200  cc.  of  each  urine  o'5  gramme  of 
dried  uric  acid,  and  subsequently  filtering  and  weighing 
after  digesting  for  twenty  minutes  at  37°  C.  A  urine 
which  spontaneously  deposited  uric  acid  also  deposited  uric 
acid  when  passed  after  draughts  of  Assmannshausen,  Wies- 
baden, and  Salzschlirf  waters.  Fachingen,  Vichy,  and 
Wildungen  waters  caused,  on  the  contrary,  part  of  the 
added  uric  acid  to  be  taken  up  by  the  urine,  Fachingen 
water  being  the  most  effectual  in  this  respect.  Fiirst 
arrives  at  the  conclusion  that  the  solvent  power  of  springs 
depends  upon  the  total  amount  of  carbonated  bases  they 
contain,  and  that  calcium  bicarbonate  and  potassium  bi- 
carbonate are  as  effectual  as  the  sodium  salt. 

The  virtue  of  the  milder  calcareous  mineral  springs  is 
probabl}^  due  to  their  harmlessness,  which  permits  con- 
siderable libations  to  be  indulged  in.  If,  as  often  occurs, 
they  should  contain  feeble  proportions  of  diuretic,  laxative, 

*  Deutsche  Medisinal  Zcititng,  January,  1893  (quoted  by  Levison). 


THE  CALCAREOUS  WATERS  497 

ferruginous,  or  alterative  salts,  these  salts  acquire  pro- 
gressive activity  in  proportion  to  the  bulk  of  the  fluid 
ingested,  and,  owing  to  their  great  dilution,  their  action  is 
combined  with  a  minimum  of  irritation. 

The  Special  Indications. — Dr.  Galland-Gleize,  in  an  in- 
teresting monograph  on  '  The  Mineral  Waters  of  Vittel,' 
and  these  may  be  taken  as  a  fair  sample  of  the  group  of 
bicarbonated  and  sulphated  calcic  waters,  dwells  upon 
their  eupeptic,  diuretic,  laxative,  and  cholagogue  effects,  and 
claims  for  them  a  stimulating  action  on  general  meta- 
bolism and  a  depurative  action  for  uric  acid,  the  excretion 
as  well  as  the  production  of  which  are  ultimately  reduced. 
He  finds  them  well  suited  for  all  forms  and  phases  of  gout, 
and  specially  suited  for  the  visceral  complications  of  gouti- 
ness, whether  gastric,  renal,  hepatic,  or  glycosuric,  and  for 
biliary  and  urinary  lithiasis.  In  vesical  and  prostatic 
catarrh  they  are  also  of  much  value. 

The  diuretic,  laxative,  and  cholagogue  action  is  suf- 
ficiently explained  by  the  presence  of  sulphate  of  sodium 
and  of  magnesium  ;*  the  eupeptic  action  not  only  by 
these,  but  probably  by  the  sedative  action  of  carbonic 
acid  gas,  and  by  the  calcium  carbonate  and  sulphate. 
Two  to  eight  glasses  are  to  be  drunk  fasting  at  short 
intervals  in  the  morning,  and  one  to  three  glasses  four 
hours  after  lunch.  He  warns  against  the  excessive 
amounts  sometimes  taken  by  patients.  The  individual 
allowance  should  be  carefully  regulated  by  the  physician. 

*  Dr.  Galland-Gleize  claims  for  the  water  of  Vittel  that  it  is  rela- 
tively more  magnesian  and  less  calcareous  than  that  of  Contrexdville, 
and  therefore  more  purgative  and  also  more  digestible. 


32 


CHAPTER  LIV. 

THE  USES  AND  SELECTION  OF  MEDICINAL 
SPRINGS  {Continued). 

THE  MURIATED  WATERS. 

General  Indications. — The  value  of  sodium  chloride 
springs  in  gout  is  a  much  vexed  question.  Of  their  value 
in  various  other  affections  no  doubt  can  be  entertained.  As 
in  the  case  of  lime,  the  diluted  solutions  of  sodium  chloride 
can  be  taken  in  large  quantities,  and,  aided  by  the  bulk  of 
water,  the  special  activities  of  the  salt  come  into  play. 

1.  Foremost  among  the  therapeutic  properties  of  sodium 
chloride  is  its  diffusihility,  which  enables  it  to  visit  every 
part  of  the  body.  Substances,  and  in  particular  urea, 
with  which,  according  to  some  physiologists,  soluble  com- 
binations or  double  salts  are  formed,  may  by  this  means 
be  more  readily  washed  out  of  the  tissues  and  excreted. 

2.  Probably,  by  facilitating  and  accelerating  the  circula- 
tion of  the  juices,  it  promotes  metabolism,  and  lessens  the 
tendency  to  various  concretions. 

3.  It  promotes  appetite  as  a  stimulant  to  the  sense  of 
taste,  and  as  a  stimulant  to  the  gastric  mucous  membrane. 

4.  It  supplies  the  stomach  with  the  hydrochloric  acid, 
and  the  liver  with  the  sodium,  which  they  need  for  their 
respective  secretions.  It  is  therefore  a  digestive  and  hepatic 
stimulant. 


THE  MURIATED   WATERS  499 

Among  its  peptic  properties,  Stadelmann  has  pointed 
out  its  power  of  increasing  the  tolerance  of  the  stomach 
for  large  doses  of  sodium  bicarbonate,  as  much  as  20 
or  30  grammes  of  which  have  been  taken  per  diem  in 
diluted  solutions  of  sodium  chloride  and  of  carbonic  acid 
gas. 

Dr.  Hermann  Weber  dwells  on  the  influence  which  it 
exerts  upon  metabolism,  through  the  secreting  apparatus 
of  the  bowel  and  through  the  portal  system,  and  holds 
that  it  quickens  tissue-change,  and  thus  *  promotes  the 
absorption  of  pathological  products  without  lowering 
the  organism.  In  larger  doses,  however,  beyond  about 
5  drachms  per  diem,  irritation  of  the  mucous  membrane 
of  the  stomach  and  intestines  may  be  produced.' 

In  most  of  the  muriated  springs  the  effects  are  modified 
by  the  presence  of  carbonic  acid,  which  acts  as  a  sedative 
on  the  nerves  of  the  stomach,  whilst  stimulating  the  secre- 
tion and  the  peristalsis.  It  may,  of  course,  produce  tem- 
porary dilatation.  More  commonly,  any  excess  is  absorbed 
or  dispelled. 

Other  salts  often  occur  in  small  proportions  in  the 
muriated  springs,  and  their  properties  will  have  to  be  taken 
into  account. 

The  Muriated  Baths. — Considerable  attention  has  of  late 
been  directed  to  the  specific  effects  upon  the  heart  of  the 
hot  springs  of  Nauheim,  which  contain  an  abundance  of 
carbonic  acid  gas  in  addition  to  sodium  and  calcium 
chloride.  This  subject  is  not  foreign  to  gout,  some  of  the 
visceral  complications  of  which  are  cardiac.  Moreover, 
the  cardiac  effect  of  the  baths  is  held  to  be  largely  due  to 
a  general  influence  on  the  metabolism.  Absorption  of  the 
salt  through  the  skin  probably  does  not  take  place. 
Neither  is  iflikely  that  any  considerable  amount  of  water 
should  be  drawn  from  the  body  by  the  strong  saline  bath. 


Soo  THE  MURIATED  WATERS 

There  is,  however,  Httle  doubt  that  the  combined  action 
of  the  salt  and  of  the  carbonic  acid  stimulates  the  nerve 
endings  and  capillaries  of  the  skin,  and  through  them  the 
nerve  centres,  and,  in  a  reflex  way,  the  entire  organism. 

The  Special  Indications. — The  debility  of  convalescence, 
of  most  forms  of  anaemia,  and  especially  of  chronic  dys- 
pepsia, or  of  chronic  hepatic  inadequacy  or  congestion,  is 
the  indication  specially  applicable  to  the  group  of  gouty 
ailments,  although  many  other  conditions  foreign  to  gout 
are  benefited. 

Among  gouty  cases,  those  are  held  to  be  specially  suited 
for  this  treatment  which  do  not  present  the  indications  for 
the  more  searching  saline  mineral  springs.  Thus,  ac- 
cording to  Dr.  Hermann  Weber,  '  the  muriated  alkaline 
waters  of  Royat,  Ems,  or  Baden-Baden  are  suited  to  the 
more  delicate  constitutions ;  and  for  lean  and  weak  gouty 
subjects  the  simple  muriated  springs  of  Homburg,  Kissin- 
gen,  Harrogate,  and  Leamington,  the  arsenical  waters  of 
Levico,  the  waters  of  Wiesbaden,  and  the  muriated  sulphur 
waters  of  Aix-la-Chapelle,  deserve  a  trial. 

The  subject  of  the  Wiesbaden  waters  will  be  referred  to 
in  a  subsequent  chapter. 

SODIUM  CHLORIDE  AND  THE  BIURATE— 
SIR   W.  ROBERTS'   VIEWS. 

Thanks  to  the  diffusibility  of  common  salt,  which  allows 
it  to  be  separated  from  the  blood  and  discharged  through 
the  kidneys  with  great  rapidity,  a  fixed  proportion  of 
sodium  chloride,  which  healthy  blood  tenaciously  retains, 
is  never  much  exceeded.  Beyond  this  blood  serum  will 
not  allow  itself  to  be  permanently  charged.  On  the  other 
hand,  whilst  any  overdose  would  lead  merely  to  a  tem- 
porary surplus,  any  deficiency  in  the  intake  would  have  to 
be  made  up  to  the  blood  from  the  tissues.    Sir  W.  Roberts 


SODIUM  CHLORIDE  AND  THE  BIURATE  501 

quotes  on  this  point  the  results  of  Dastre  and  Loye,*  who 
have  shown  that,  if  not  otherwise  suppUed,  the  blood  will 
extract  salt  from  the  less  vital  fluids  and  tissues,  and 
that,  if  over-supplied,  it  will  discharge  some  of  the  excess 
into  the  serous  cavities  pending  the  restoration  of  the 
normal  equilibrium  by  the  kidneys.  On  this  showing,  he 
points  out  that  a  diminished  intake  of  salt,  whilst  not 
materially  altering  the  proportion  present  in  the  blood, 
would  considerably  lessen  its  proportion  in  the  synovial 
fluids  and  in  the  fibrous  tissues. 

The  Influence  of  Common  Salt  as  an  Article  of  Diet  ift  Gout 
and  Gravel. — Assuming,  then,  that  in  health  it  matters 
little  whether  we  consume  much  or  little  salt  over  and 
above  the  bare  requirement,  the  further  question  arises  as 
to  the  influence  of  sodium  chloride  in  gout.  According  to 
Sir  W.  Roberts'  investigations,  solutions  of  salt  exert  no 
influence  whatever  on  crystals  of  free  uric  acid,  but  their  in- 
fluence on  the  solubility  of  the  sodium  biurate  is  most 
marked :  in  his  maturation  experiments  so  small  a  quantity 
as  o"i  per  cent.,  or  even  less,  added  to  blood  serum,  appreciably 
hastened  the  precipitation  of  the  crystalline  biurate.  Conse- 
quently the  amount  of  sodium  chloride  moving  in  the 
economy  is  not  regarded  by  him  as  a  matter  of  indiffer- 
ence in  gout ;  at  the  approach  of  any  threatenings  of 
uratic  precipitation,  if  it  were  possible,  it  would  be  desirable 
to  keep  down  its  percentage  in  the  joints  most  threatened. 
Sir  W.  Roberts  does  not  therefore  hesitate  to  recommend 
gouty  patients  to  restrict  as  far  as  possible  the  use  of 
common  salt  at  their  meals. t      Since  no  harm  attaches  to 

*  'Lavage  du  Sang  :'  'Archives  de  Physiologic,'  1888,  p.  93. 

t  Between  this  recommendation  and  the  danger  of  completely  de- 
priving the  joints  of  their  normal  amount  of  sodium  chloride,  there  is 
a  wide  margin.  Yet,  to  secure  any  effectual  diminution  within  them, 
the  percentage  of  salt  in  the  economy  would  have  to  be  lowered,  by 


502  SODIUM  CHLORIDE  AND  THE  BI URATE 

retrenchment,  and  as  an  excessive  use  of  salt  must  be 
regarded  with  suspicion,  great  moderation  is  obviously 
the  wisest  course,  in  gout. 

In  gravel,  an  affection  which  is  regarded  by  Sir  W. 
Roberts  as  alternating  rather  than  coinciding  with  gout,* 
the  influence  of  sodium  chloride  is  totally  different,  and 
the  indications  for  its  use  are  exactly  opposite.  Although 
salt  possesses  no  solvent  power  for  solid  uric  acid,  it 
retards  the  decomposition  of  quadriurates,  and  therefore  the 
precipitation  of  uric  acid.-  This  explains  the  remarkable 
immunity  of  the  inhabitants  of  the  '  marshland  '  of  Nor- 
folk, f  where  the  water  is  brackish,  and  that  of  seafaring 
men,  who  take  a  prodigious  amount  of  salt  with  their  food, 
and  the  no  less  remarkable  frequency  of  stone  among  the 
natives  of  India,  who  live  on  rice,  of  all  food-stuffs  the 
poorest  in  mineral  constituents  (only  o'39  per  cent.),|  and 
among  the  poor  in  general. 

Precipitation  of  uric  acid  is  also  favoured  by  a  deficiency 
in  the  it,rinary  pigments,  by  a  high  percentage  of  uric  acid, 
and,  above  all,  by  the  degree  of  acidity. 

The  influence  of  a  minute  addition  of  an  alkaline  bicar- 
bonate in  postponing  the  precipitation  of  uric  acid  is  shown 
in  Sir  W.  Roberts'  tabulated  observations  : 


very  strict  rules  of  diet,  to  an  extent  not  free  from  all  risk.  Moreover, 
further  evidence  is  needed  as  to  the  relative  facility  with  which  synovia 
and  the  joint  structures  would  allow  themselves  to  be  deprived  of  their 
sodium  chloride. 

*  Mr.  C.  Plowright,  '  On  the  Cause  and  Distribution  of  Calculous 
Disease,'  London,  1886  (quoted  by  Sir  W.  Roberts),  points  out  that 
Norfolk,  one  of  the  chief '  stone '  districts,  has  a  comparatively  small 
gouty  record.     In  Scotland,  where  gout  is  rare,  stone  is  common. 

t  Cf.  Plowright,  Medical  Times  and  Gazette,  October  10,  1885. 

%  The  relative  quantity  of  mineral  matter  is,  for  meat  and  fish,  5  to 
5*50  per  cent.  ;  for  milk,  5*50  ;  for  oatmeal  and  for  potato,  2' 50  ; 
for  wheaten  flour,  o"5i  only  (Roberts). 


SODIUM  CHLORIDE  AND  THE  BIURATE  503 

Time  of  postpone- 

precipitation  ^^^^^^^ 

(hours).  ^  ' 

No.  I  urine  (no  addition)       -  -         2  — 

No.  2  urine  (added :  0*04  per  cent. 

potassium  bicarbonate)      -  -         4  2 

No.  3  urine  (added  :  0*04  per  cent. 

sodium  bicarbonate)  -  -         5  3 

No.  4  urine  (added  :   0*04  per  cent. 

lithium  bicarbonate)  -  -       10  8 

In  all  these  urines  litmus -paper  hardly  showed  any 
change,  so  small  was  the  proportion  of  the  alkaline 
addition.  The  difference  in  the  delays  recorded  is  de- 
scribed as  a  mere  question  of  atomic  weight,  and  of 
saturating  power  of  the  several  salts. 

The  Influence  of  the  Muriated  Mineral  Waters  in  Gout  and 
in  Gravel. — On  the  basis  of  the  chemical  observations 
which  have  been  detailed,  cases  of  gravel  and  of  stone 
would  derive  the  greatest  advantage  from  the  internal  use 
of  the  muriated  waters,  and  especially  of  those  containing 
alkaline  bicarbonates  in  addition  ;  but  in  gout  the  circu- 
lation of  so  much  additional  sodium  chloride  might  lead 
to  a  recrudescence  of  the  symptoms  by  favouring  the 
precipitation  of  the  biurate. 

GENERAL  CONCLUSIONS. 

In  practice  the  theoretical  objections  which  have  been 
urged  have  not  been  confirmed  by  experience  in  a  degree 
sufficient  to  deter  all  gouty  patients  from  the  use  of  the 
waters.  The  reasons  for  this  discrepancy  between  the 
results  and  the  theory  are  not  far  to  seek.  The  hydration 
of  the  tissues  and  the  flushing  of  the  lymphatics,  including 
those  of  the  gouty  joints,  by  copious  and  systematic  sup- 
plies of  water,  introduce  an  element  which  is  antagonistic 
to  the  tendency  to  sedimentation,  and  the  latter  is  also 


504  GENERAL  CONCLUSIONS 

counteracted  in  many  by  the  active  life  which  is  an  essential 
part  of  the  cure. 

Moreover,  many  of  the  muriated  wa,ters  are  also  feebly 
carbonated,  and  convey  the  antidote  together  with  the 
poison,  if  the  latter  expression  could  be  applied  to  common 
salt.   . 

There  is,  however,  another  and  more  important  aspect 
of  the  cure.  Gout,  as  we  have  often  insisted,  does  not 
begin  at  the  uric  acid  stage ;  there  is  an  antecedent 
factor.  Water,  as  Garrod  has  himself  pointed  out, 
*  stimulates  the  entire  metabolism,  increasing  the  various 
secretions.  To  this  general  action  the  mineral  con- 
stituents add  their  own  special  influences,'  which  in  the 
case  of  sodium  chloride  is  admittedly  a  stimulating  in- 
fluence. Any  danger  to  be  dreaded  from  the  precipitation 
of  the  biurate  may  thus  be  happily  forestalled  by  obviating, 
through  an  improvement  in  the  metabolism,  the  excessive 
production  or  accumulation  of  uric  acid  itself.  By  check- 
ing the  mischief  at  the  fountain-head,  we  are  spared  the 
task  of  correcting  its  later  developments. 


CHAPTER  LV. 

THE    USES   AND    SELECTION    OF    MEDICINAL 
SPRINGS  (Continued). 

THE  SODIC  CARBONATED  WATERS. 

Sodium  is  the  metal  to  which  the  alkahne  waters  owe 
their  alkahnity ;  any  question  as  to  its  action  in  gout 
opens  up  the  question  as  to  the  suitabiHty  of  the  whole 
group. 

Objections  have  been  urged  against  it,  which  may  be 
classed  as  clinical  and  chemical.  The  stronger  sodic 
waters  have  been  accused  of  occasioning  a  recrudescence 
of  the  arthritic  trouble,  of  imperfectly  relieving  visceral 
gout,  and  of  producing  more  than  the  usual  nervous  dis- 
turbance, or  even  definite  nervous  complications.  Some 
of  this  criticism  may  have  been  over-anxious,  and  in 
some  instances  not  free  from  partisanship.  It  should  be 
remembered,  as  suggested  by  Lyman,  that  any  spring  of 
world-wide  fame,  such  as  Vichy,  must  attract  not  only  the 
greatest  numbers,  but  among  them  also  the  worst  cases  ; 
and  it  is  notorious  that  the  latter  are  not  always  the  best 
suited  for  energetic  treatment. 

Among  the  clinical  objections,  it  is  alleged  that  the  strong 
sodic  waters  are  exciting  and  congesting ;  that  if  given  in  suffi- 
cient dose  to  influence  the  dyscrasia  they  are  debilitating. 
Lastly,  it  is  thought  of  some  of  them  that  they  are  apt  to 
constipate.     The  subject  of  the  alleged  alkaline  cachexia 


5o6  THE  SODIC  CARBONATED  WATERS 

has  been  already  discussed.  The  other  objections  de- 
serve to  be  carefully  weighed.  It  must  be  admitted  that 
even  the  physicians  who  prescribe  the  Vichy  waters  do 
not  contend  that  they  are  suitable  to  all  stages,  as  this  is 
claimed  elsewhere  for  some  other  waters.  The  supposed 
constipating  effect  is  one  which  it  might  be  possible  to 
remedy ;  nevertheless,  it  may  sometimes  account  for  an 
imperfect  relief  of  the  general  and  local  symptoms  in 
gout. 

It  has  not  been  disputed  that  the  stronger  alkaline 
waters  are  the  most  potent  in  the  treatment  of  gravel  and 
of  urinary  concretions,  although  they  no  longer  enjoy  their 
previous  monopoly  in  this  respect. 

The  most,  then,  that  can  be  said  against  these  waters — 
against  the  Vichy  and  Vals  waters  in  particular — is  that 
they  are  not  always  well  borne  by  debilitated  subjects  ;  that 
they  are  not  suited  to  acute  stages ;  that  they  may  some- 
times prove  insufficiently  laxative,  or  even  constipating. 
In  some  cases,  probably  those  of  idiosyncrasy,  they  may 
not  be  easily  digested,  and  may  set  up  various  nervous 
symptoms. 

The  chemical  objection  is  a  formidable  one.  It  has  been 
fully  stated  by  Sir  \V.  Roberts,  and  we  have  referred  to 
it  in  previous  remarks.  An  excess  of  sodium  in  the 
system,  per  se,  might  doubtless  favour  the  formation  and 
precipitation  of  sodium  biurate,  but  we  may  repeat  that 
'  everything  depends  upon  the  circulation.'  If  the  sodium 
bicarbonate,  and  if  the  uric  acid  itself,  can  be  kept  moving, 
the  danger  in  question  is  to  a  great  extent  averted.  Any 
sudden  check  to  the  lymphatic  circulation  might  con- 
ceivably, in  a  person  over-saturated  with  sodium,  lead  to 
an  easier  precipitation  of  the  biurate.  So  long,  however, 
as  the  excretory  organs  are  in  full  activity,  and  the  liver 
relieved  by  a  sufficiently  laxative  treatment,  the  general 
advantages  of  sodium  may  be  secured  without  any  serious 


THE  SODIC  CARBONATED  WATERS  507 

arthritic  danger.  Much  will  depend  upon  the  degree  of 
dilution,  and  upon  the  nature  of  the  other  mineral  con- 
stituents of  the  waters. 

The  empirical  repibtation  enjoyed  by  sodium  has  received 
a  striking  illustration  in  connection  with  a  celebrated 
mineral  spring  which  happens  to  lack  the  sodium  bicar- 
bonate. The  attempt  has  been  made  to  improve  upon 
nature  in  this  respect.  Hitherto  we  had  been  content 
with  raising  the  temperature  of  mineral  springs  for 
bathing  purposes.  The  new  departure  of  adding  a  fresh 
chemical  constituent  is  a  shock  to  sentiment  in  connec- 
tion with  mineral  waters  ;  but  it  conveys  a  practical 
lesson.  The  flattery  of  imitation  reflects  the  opinion 
entertained  at  Wiesbaden  of  the  value  of  Vich}^  waters  in 
connection  with  their  sodium  salts.  The  '  Wiesbaden 
gout-water  '  is  doubtless  an  excellent,  though  an  artificial, 
combination  ;  but  it  has  out-Vichied  Vichy  by  raising  the 
proportion  of  the  sodium  bicarbonate  from  5  (Celestins) 
to  8  pro  mille. 

MORDHORSTS   VIEWS   AS  TO  THE   VALUE  OF   SODIUM 
BICARBONATE  IN  GOUT. 

Mordhorst,*  who  is  a  strong  advocate  of  the  artificial 
Wiesbaden  '  Gicht-wasser,'  uses  the  following  arguments, 
among  others,  in  favour  of  the  administration  of  sodium 
bicarbonate  : 

'  I.  Increased  alkalescence  of  the  plasma,  and  conse- 
quently also  of  the  tissue  cell  contents,  augments  their 
capacity  for  absorbing  and  retaining  oxygen,  thereby 
assisting  and  increasing  the   processes   of  oxidation  and 

*  '  The  Remedies  which  are  applicable  in  the  Treatment  of  Gout 
and  Uric  Acid  Concretions,  and  their  Mode  of  Action  :'  a  lecture 
delivered  at  the  Eleventh  International  Medical  Congress  in  Rome, 
1894  ;  with  a  postscript  by  Carl  Mordhorst,  M.D.  Kiel,  Wiesbaden  ; 
translated  by  Ronald  E.  S.  Krohn,  M.D.  Lond.  Rome  :  Loescher 
and  Co.  ;  1895. 


5o8  THE  VALUE  OF  SODIUM  BICARBONATE 

decomposition.  It  is  evident  therefore  that,  with  a 
diminution  of  the  quantity  of  uric  acid  in  the  fluids  of 
the  body,  the  danger  of  its  precipitation  and  deposition 
in  the  tissues  is,  other  conditions  being  equal,  propor- 
tionately diminished. 

'  2.  The  fact,  demonstrated  by  Maly,  Chabrie,  Rune- 
berg,  Hoffmann,  and  others,  that  acids  and  acid  salts 
diffuse  and  filter  more  rapidly  through  animal  tissues  than 
do  bases  and  alkaline  salts,  explains  the  circumstance  that 
in  gout,  where  the  alkalinity  of  the  blood  is  abnormally 
low,  those  tissues  which  are  not  supplied  with  blood 
capillaries,  and  only  communicate  with  them  by  osmosis, 
namely,  the  fibrous  tissues,  must  be  less  alkaline,  often 
neutral,  or  even  acid  in  reaction,  and  must  be  predisposed 
to  the  deposition  of  urates. 

'  3.  The  more  alkaline  the  tissue  plasma  is,  the  greater 
is  its  power  to  keep  uric  acid  in  solution.* 

*  4.  The  more  alkaline  the  tissue  plasma  of  the  body  is, 
the  greater  is  the  decomposition  of  any  already  formed 
uric  acid.  The  correctness  of  this  statement  has  been 
proved  by  the  experiments  of  a  large  number  of  authors. 
They  all  found  a  considerable  reduction  (up  to  30  per 
cent,  or  more)  in  uric  acid  after  the  administration  of 
large  doses  of  bicarbonate  of  soda. 

*  '  The  startling  results  obtained  by  Biesenthal  in  his  experiments 
on  cocks  and  pigeons,  which  had  been  simultaneously  treated  with 
piperazine  and  neutral,  potassium  chromate^  show  that  it  is  possible  to 
prevent  the  deposition  of  uric  acid  which  results  from  subcutaneous 
injections  of  potassium  chromate,  according  to  Ebstein's  procedure,  by 
the  administration  of  large  doses  of  piperazine,  and  even  to  dissolve 
any  such  deposits  when  already  present.  The  heroic  doses  given  to 
the  animals  experimented  on,  viz.,  0*5  gramme  to  the  cocks,  o'2  to  0*5 
gramme  daily  to  the  pigeons,  calculated  in  proportion  to  the  body 
weight,  would  correspond  to  30  to  75  grammes  for  an  adult  weighing 
75  kilogrammes.  There  can  be  no  doubt  but  that,  after  such  treatment, 
the  tissues  of  the  animals  must  become  markedly  alkaline'  (Mordhorst, 
loc.  cit.). 


THE   VALUE  OF  SODIUM  BICARBONATE  509 

'5,  Biurates*  (in  needle  crystals)  are,  as  well  as  uric 
acid,  far  more  soluble  in  0'6  to  o"8  per  cent,  solutions  of 
sodium  bicarbonate  than  in  either  stronger  or  weaker 
solutions  or  in  distilled  water.  In  the  latter  they  are 
decomposed,  uric  acid  being  precipitated  and  the  solution 
becoming  alkaline. 

'  6.  Large  doses  of  potassium  carbonate  cannot  be  given, 
as  they  depress  the  heart's  action.  Lithium,  according  to 
Paul  Binet,t  is  the  most  poisonous  of  all  alkalies  and 
alkaline  earths.  W.Stirling:}:  considers  lithium  to  be  far 
more  poisonous  than  is  usually  supposed  to  be  the  case. 
Posner  and  Goldenberg's  §  experiments  prove  that  lithium 
carbonate  reappears  in  the  urine  to  a  great  extent  as 
lithium  chloride.  HaigH  states  that  in  the  living  organism 
lithium  exerts  no  solvent  action  on  uric  acid  whatever. 
According  to  Rose,^  lithium  forms  an  almost  insoluble 
triple  phosphate  with  bisodium  phosphate  or  with  the 
triple  phosphate  of  ammonium  and  sodium.  This  much, 
however,  is  certain  :  on  account  of  its  poisonous  properties 
lithium  can  only  be  administered  in  such  small  doses, 
that  to  speak  of  alkalization  of  the  blood  or  lymph  taking 
place  after  its  use  is  out  of  the  question. 

'  7.  There  only  remain,  therefore,  the  carbonates  of 
sodium.  When  taken  in  mineral  waters,  and  when  too 
much  is  not  taken  at  a  time,  sodium  bicarbonate  is  well 
borne.      The  water  must,  hov/ever,   contain  neither  too 

*  Roberts'  quadriurates  are  regarded  by  Mordhorst  as  biurates  in 
a  globular  form.  Roberts'  experiments  with  blood  serum  are,  in  his 
opinion,  not  conclusive  ;  for  both  blood  and  serum  become  acid  as 
soon  as  they  leave  the  living  body,  even  after  alkalies  have  been 
added  (Hoppe-Seiler  and  Landois). 

f  Gaz.  Medic,  de  Paris,  1892. 

%  Journal  of  Anatomy  and  Physiology,  1892. 

§  Zeitschrift  fiir  Minis che  Medisin,  Bd.  13,  Heft  6,  1888,  p.  581. 

II  '  Uric  Acid,'  p.  30.     London,  1892. 

"^  'Chemical  Analysis,'  p,  15. 


5IO  THE  VALUE  OF  SODIUM  BICARBONATE 

much  calcium  carbonate,  nor  too  little  sodium  chloride ; 
for  Kleine  has  pointed  out  that  it  is  possible  by  using 
sodium  carbonate  to  abstract  gradually  a  considerable 
amount  of  chlorine  from  the  body.  A  removal  of  acids, 
in  the  true  sense  of  the  term,  is  the  consequence  of  the 
administration  of  alkalies.' 

In  conclusion,  Mordhorst  claims  that  the  Wiesbaden 
'  gout-water '  has  stood  the  test  of  practical  experience ; 
that  it  can  be  taken  contirmously  for  years,  which  is  not 
the  case  with  Vichy,  Vals,  Fachingen,  and  other  cal- 
careous waters,  for  they  are  often  badly  borne,  producing 
constipation,  inappetency,  restlessness,  etc. ;  that  it  con- 
tains nearly  twice  as  much  bicarbonate  and  fourteen  times 
as  much  chloride  of  sodium  as  contained  in  the  Celestins 
Spring,  with  one-fifth  of  the  amount  of  lime  salts,  and 
double  the  amount  of  solid  constituents,  and  nearly  three 
times  as  much  bicarbonate  and  eleven  times  as  much 
chloride  of  sodium  as  contained  in  Fachingen  water,  with 
one-seventh  of  the  amount  of  lime  salts,  and  three  times  as 
much  solid  constituents  ;  that  it  is  the  only  water  which 
will  render  even  the  most  acid  urine  alkaline  without 
causing  it  to  become  turbid ;  and  that  when  taken  even 
in  moderate  quantities  (two  bottles  daily),  it  will  exert  a 
very  much  greater  solvent  action  on  calculi,  even  of  large 
size,  than  Vals  water. 

The  case  thus  made  out  empirically  in  favour  of  the 
use  of  bicarbonate  of  sodium  must  be  admitted  as  out- 
weighing the  theoretical  objections  which  have  been  raised 
against  it.  It  may  be  argued  that  just  as  the  beneficial 
effects  of  sodium  in  gout  are  largely  due  to  its  effect  on 
the  liver,  the  intercurrent  gouty  attacks  often  witnessed 
at  sodic  mineral  springs  may  be  induced  less  by  the 
sodium  itself  than  by  other  constituents  of  these  waters, 
which  may  cause  in  some  subjects  a  primary  gastric  and 
hepatic  disturbance,  with  gouty  arthritis  as  its  result. 


CHAPTER  LVI. 
CONCLUDING  REMARKS. 

THE  HOME  SPAS, 

Practical  indications  for  a  selection  of  springs  may  be 
gathered  from  what  has  preceded. 

In  plethoric  gout  associated  with  imperfect  action  of  the 
hver,  or  chronic  hepatic  congestion  and  its  attendant 
symptoms,  the  order  of  efficiency  of  the  springs  would  be 
as  follows :  the  alkaline  sulphated,  the  alkaline  earthy,  the 
muriated  sulphated,  and  the  sulphurous  springs.  The 
alkaline  springs  are  also  available,  but  additional  medica- 
tion may  be  needed  besides  the  waters  ;  and  here,  more 
even  than  at  any  of  the  other  resorts,  the  constant  advice 
of  a  competent  physician  is  indispensable.  The  indifferent 
waters  will  also  prove  of  advantage  within  the  range  of 
their  capabilities,  when  supplemented  with  any  necessary 
medicinal  adjuncts. 

Where  acidity  predominates,  whether  of  the  stomach  or 
of  the  secretions,  the  alkaline  waters  are  indicated.  But 
they  are  not  the  only  means  of  treatment.  Here,  again, 
the  indifferent  waters  may  effect  much  on  the  '  washing- 
out  '  principle  ;  but  more  direct  good  will  accrue  from  the 
alkaline  earthy  springs.  With  all  due  precautions,  the 
sulphurous  springs  may  also  prove  beneficial. 

Uratic  concretions  of  all  kinds  are  treated  by  the  alkaline 
and  by  the  alkaline  earthy  springs. 


512     THE  MEDICINAL  SPRINGS  IN  GREAT  BRITAIN 

Diabetes  and  glycosuria  are  widely  benefited  by  various 
springs,  a  great  deal  of  the  good  being  dependent  upon 
the  attention  paid  to  diet.  Any  mild  action  taken  on  the 
liver  is  always  beneficial.  The  most  celebrated  resorts  in 
these  affections  are  Neuenahr,  Carlsbad,  Wiesbaden, 
Vichy,  Vittel,  Contrexeville  ;  and  their  treatment  from  the 
nervous  side  is  also  represented  at  the  various  arsenical 
springs. 

The  same  indications  which  apply  to  foreign  resorts 
will  be  our  guides  in  the  selection  of  the  British  springs. 
These  deserve  special  notice  owing  to  the  greater  numbers, 
and  to  the  longer  time  for  which  some  of  them  are  avail- 
able. 

THE  MEDICINAL  SPRINGS  IN  GREAT  BRITAIN. 

The  British  spas  can  often  be  reached  by  those  whose 
opportunities  do  not  allow  of  distant  travel.  Many  have 
not  the  means  of  attempting  a  long  journey  or  of  meeting 
the  expenses  incidental  to  a  residence  abroad.  Again, 
those  more  advanced  in  years  are  unfit  or  disinclined  for 
so  great  a  change.  For  all  these  the  home  resorts  present 
the  facilities  required — hospitals  being  provided  for  the 
needy,  and  house  accommodation  proportionate  to  every 
income. 

The  Air-Cure  and  the  Water-Cure. — An  excellent  air-cure 
for  convalescents  may  be  made  at  Clifton,  Malvern,  Tun- 
bridge  Wells,  Matlock,  Buxton,  and  many  other  places. 

The  water-cure  is  that  most  universally  indicated  in  all 
forms  of  gout.  Putting  aside  Matlock,  where  the  waters 
only  reach  68°  Fahr.,  Bath  and  Buxton  are  the  chief  repre- 
sentatives of  the  best  form  of  water-cure,  the  thermal. 

Bath  has  a  reputation  as  ancient  as  the  history  of  Great 
Britain,  and  which  shows  every  sign  of  increasing.  Its 
waters    are   the    hottest    in   this   country,  ranging  up  to 


THE  MEDICINAL  SPRINGS  IN  GREAT  BRITAIN     513 

120°  Fahr.  They  are  available  the  whole  year  round ; 
but  spring  and  autumn  are  regarded  as  special  seasons  for 
treatment. 

The  Buxton  waters  are  supposed  to  have  been  used  by 
the  Romans,  but  had  not  been  in  fashion  until  the  end  of  the 
sixteenth  century,  Buxton's  bracing  climate  adds  greatly 
to  its  value  as  a  health  resort,  but  restricts  its  benefits  to 
the  summer  season.  Although  the  constituents  of  the  waters 
are  varied,  they  are  present  in  such  small  quantities  as  to  be, 
with  the  exception  of  iron  and  calcium,  probably  inactive. 

At  both  resorts  the  internal  use  of  the  water  is  combined 
with  its  external  use,  which  may  be  regarded  as  the  most 
valuable. 

A  large  number  of  gouty  patients,  for  whom  more  ener- 
getic treatment  is  not  needed,  will  be  benefited  by  the  water- 
cure  ;  and  •  the  same  applies  to  those  suffering  from  the 
various  troubles  of  goutiness,  although  neuralgic  patients, 
as  often  happens,  may — especially  at  Buxton — suffer  at 
first  a  slight  recrudescence  of  pain,  probably  connected 
with  the  exciting  effects  of  the  air  and  of  the  treatment. 

Although  in  Great  Britain  the  groups  of  mineral  waters 
are  not  all  represented,  considerable  efficacy  attaches  to 
those  which  we  possess. 

The  most  important  are  the  thermal  springs  of  Bath  and 
Buxton,  and  the  sulphur  and  sodium  chloride  springs  of 
Harrogate  and  Strathpeffer  (both  these  spas  also  have 
chalybeate  springs),  and  of  Llandrindod,  which  also  has 
important  saline  and  chalybeate  waters.  Llanwrtyd, 
Builth,  Moffat  (near  Dumfries),  and  Lisdoonvarna  (in 
Ireland)  should  not  be  forgotten  among  the  sulphurous 
springs. 

Cheltenham*  is  the  almost    solitary  representative   of 

*  Cf.  Dr.  Archibald  E.  Garrod's  report  in  '  The  Climates  and  Baths 
of  Great  Britain,'  p.  589. 

33 


514      THE  MEDICINAL  SPRINGS  IN  GREAT  BRITAIN 

the  sulphurated  saHne  group ;  it  has  been  strangely  neg- 
lected, although  at  one  time  a  flourishing  and  useful  resort. 
Cheltenham  also  possesses  a  chalybeate  spring  at  the 
Cambray  Spa. 

The  Leamington  waters  are  of  the  sulphated  muriatic 
type,  and  compare  with  those  of  Homburg,  Kissingen, 
Soden,  Salins-Moutiers,  and  Wiesbaden,*  but  are  richer 
in  magnesium  sulphate  than  most  of  these. 

Lastly,  Woodhall  Spa  claims  special  virtues  in  con- 
nection with  the  bromine  and  iodine  which  its  waters 
contam,  and  with  their  temperature. 

Various  other  spas — an  account  of  which  will  be  found 
in  '  The  Climates  and  Baths  of  Great  Britain  ' — need  only 
a  brief  mention.  The  most  important  of  these  is  perhaps 
Droitwich,  which  is  not,  however,  specially  indicated  in 
ordinary  cases  of  gout.  Nantwich  also  has  brine  baths, 
and  the  baths  of  Stafford  and  of  Saltburn  belong  to  the 
same  group. 

The  springs  of  Ashby-de-la-Zouch  and  Tunbridge  Wells 
are  chalybeate ;  the  former  are  also  muriated.  Wales  is 
further  represented  by  Llangammarch  Wells,  noted  for  its 
chloride  of  barium. 

Medicinally,  the  home  resorts  fulfil  some  of  the  indica- 
tions which  have  been  sketched.  Bath  and  Buxton  will 
be  the  resorts  safely  and  successfully  visited  by  every 
variety  of  gout.  Cheltenham  would  represent  the  alkaline 
sulphated  springs,  such  as  Carlsbad,  and  would  meet  the 
requirements  in  cases  of  hepatic  inactivity,  with  all  its 
complications.  Leamington  will  suit  similar  cases,  though 
with  much  milder  effect. 

Harrogate  and  Llandrindod  head  the  list  of  the  sul- 
phurous springs ;  their  capabilities  in  the  treatment  of 
gout    are    considerable,    because    combining   the   air-cure 

*  Cy.  Dr.  Archibald  Garrod,  /oc.  ci/.,  p.  585. 


THE  MEDICINAL  SPRINGS  IN  GREAT  BRITAIN     515 

with  the  water-cure.  Acute  gout  is,  of  course,  not  suit- 
able, nor  cases  barely  convalescent ;  but  most  forms  of 
chronic  articular  gout,  many  chronic  visceral  complica- 
tions, gouty  nervous  affections  (particularly  neuralgia), 
and,  above  all,  gouty  cutaneous  affections,  will  variously 
benefit  from  the  internal  and  from  the  external  use  of  the 
waters.  Similar  advantages  on  a  smaller  scale  are  also 
obtainable  at  Strathpeffer  and  Moffat. 

Both  Harrogate  and  Llandrindod  have  the  additional 
advantage  of  chalybeate  springs  suited  to  the  later  stages 
of  convalescence  of  some  cases  of  chronic  gout. 

Woodhall  Spa  will  probably  rise  to  a  position  of  con- 
siderable usefulness,  and  is  already  doing  good  work  in 
connection  with  the  chronic  articular  results  of  gout.  Its 
chemical  constituents  give  it  a  unique  place  among  balneo- 
logical stations  in  this  country,  and  even  abroad. 

With  certain  reservations,  and  under  medical  guidance, 
great  benefit  may  be  obtained  for  some  arthritic  cases 
from  the  local  treatment  at  the  brine  baths  of  Droitwich. 

BRITISH  SPAS  FOR  ARTICULAR  GOUT. 
For  a  large  majority  of  -the  sufferers  from  articular  gout 
and  its  various  results  the  thermal  water-cure  at  Bath  or 
Buxton  is  the  best  procurable  in  this  country.  Between  the 
two  stations  the  selection  is  partly  a  question  of  seasons, 
Buxton  being  a  summer  resort,  and  Bath  more  largely 
visited  in  spring  and  autumn.  It  is  also  a  question  of  the 
relative  climates  :  the  bracing  air  of  Buxton  would  suit 
many  patients  better  than  the  less  stimulating  air  of 
Bath.  In  their  internal  as  well  as  in  their  external  uses 
the  waters  at  both  places  may  be  regarded  as  fulfilling 
analogous  indications,  and  their  harmlessness  is  such  as 
to  render  them  available  in  cases  where  the  more  active 
springs  are  to  be  avoided. 


5i6  BRITISH  SPAS  FOR  ARTICULAR  GOUT 

Of  very  wide  applicability  are  also  the  sulphurous 
springs,  and  particularly  those  of  Harrogate  and  of 
Llandrindod,  which  are  fitted  with  every  facility  for  the 
thermal  treatment.  Owing  to  their  constituents,  they 
are  not  so  universally  tolerated.  Still,  whilst  their  contra- 
indications are  more  numerous,  their  range  of  usefulness  is 
extended  to  many  other  gouty  conditions  besides  the 
articular. 

The  stiffness  and  thickening  resulting  from  repeated 
attacks  of  arthritis  are  the  chief,  if  not  the  only,  gouty 
conditions  for  which  the  brine  springs  of  Droitwich  are 
utilized.  Whether  entire  immersion  into  the  heated 
dilutions  of  the  brine  should  be  permitted,  or  whether  the 
treatment  should  be  limited  to  the  local  bath  or  to  the 
application  of  brine  compresses,  is  a  question  to  be 
decided  after  careful  consideration  in  each  case. 

The  waters  of  Woodhall  Spa  are  also  applicable  to  the 
same  class  of  cases,  and  with  analogous  reservations. 
Their  special  virtues  are  supposed  to  reside  in  the  bromides 
and  iodides,  but  it  is  essential  not  to  overlook  the  full 
charge  of  sodium  chloride  which  they  contain,  together 
with  some  calcium  and  magnesium  chloride. 

Articular  gout,  especially  in  those  of  feeble  powers  but 
requiring  some  measure  of  treatment  for  the  liver,  and  of 
help  to  elimination,  will  also  derive  benefit  from  a  course 
at  Cheltenham  or  at  Leamington. 

Cheltenham,  which  is  probably  destined  to  recover  some 
of  its  former  popularity,  on  the  strength  of  the  genuine 
value  of  its  springs,  enjoys  a  sheltered  situation,  which  is 
a  recommendation  for  many  frail  subjects. 

Leamington  has  already  secured  by  its  modern  improve- 
ments an  important  position  as  a  balneological  station. 
To  various  local  attractions  it  adds  that  of  its  vicinity  to 
many  places  of  historical  interest,  and  the  charm  of  a 
picturesque  country. 


BRITISH  SPAS  FOR  GOUTINESS  517 

SPAS  FOR  GOUTINESS  AND  GOUTY  AFFECTIONS. 

The  limited  variety  of  our  mineral  waters  is  much  more 
felt  in  the  treatment  of  goutiness,  with  its  multiple  mani- 
festations, than  in  that  of  articular  gout.  The  specialization, 
to  which  we  are  accustomed  on  the  Continent,  of  individual 
springs  to  the  treatment  of  separate  affections  is  a  refine- 
ment unknown  and  unattainable.  Most  of  all  do  we  miss 
the  alkaline,  the  alkaline  sulphated,  and  the  earthy 
sulphated  springs.  From  this  point  of  view  a  revival  of 
the  Cheltenham  baths  is  much  to  be  desired.  Our  insular 
isolation  might  almost  be  an  excuse  for  following  the 
example  of  Wiesbaden,  and  providing  an  artificial  Vichy 
spring. 

For  the  present,  the  gouty  acid  dyspepsia,  commonly 
ordered  to  Vichy  or  to  Vals  ;  the  chronic  gouty  gastric 
catarrh,  for  which  Kissingen  or  Homburg  are  recom- 
mended ;  the  plethora  and  hepatic  congestion,  for  which 
Carlsbad  or  Marienbad  are  pre-eminent ;  the  gravel  and 
lithiasis,  which  Vittel  and  Contrexeville  profess  to  cure  as 
readily  as  Vichy,  have  all  to  be  sent  alike  to  Bath,  Leaming- 
ton, or  Llandrindod,  where  special  medication  must  supply 
the  needful  differentiation  in  the  treatment. 

The  sulphur  springs,  which  we  need  not  again  enumerate, 
fill  with  complete  efficiency  the  place  of  the  Continental 
representatives  of  the  group  in  the  treatment  of  gouty 
hepatic  congestion,  intestinal  torpor,  gouty  catarrhs  of  the 
larynx,  pharynx,  and  bronchi,  gouty  cutaneous  ajfections,  and 
some  forms  of  gouty  neuralgia  and  myalgia. 

Gouty  lumbago  and  other  myalgicB,  gouty  sciatica  and 
neuralgicB  in  general  are  successfully  treated  at  Buxton 
and  at  Bath,  at  Droitwich,  Woodhall  Spa,  and  at  other 
stations  where  the  thermal  treatment  can  be  efficiently 
carried  out. 


5i8  BRITISH  SPAS  FOR  GOUTY  DIABETES 

For  the  important  group  oi  gouty  diabetes  and  glycosuria, 
none  of  our  resorts  have  yet  equalled  the  reputation  of 
Neuenahr,  Vichy,  Contrexeville  and  Vittel,  and  Carlsbad. 
The  sulphur  springs  are  not  unanimously  recommended. 
At  Bath  it  is  considered  that  the  water  is  more  suitable 
when  deprived  of  its  iron  by  cooling.  Buxton  has  not 
established  any  strong  claim  in  this  direction.  Much 
more  success  is  reported  from  Leamington,  and  a  trial  of 
this  spa  can  be  safely  recommended.  The  most  efficacious 
of  our  mineral  waters  is  said  to  be  the  saline  spring  of 
Llandrindod  Wells.  It  is  stated*  that  not  only  do  '  many 
patients  suffering  from  diabetes  frequent  this  spa  every 
year  on  account  of  the  improvement  in  their  symptoms,' 
but  that  '  in  some  instances  glycosuria  is  permanently  got 
rid  of  by  one  course  of  treatment.' 

Doubtless  the  properties  inherent  to  some  of  our  best 
mineral  waters  have  not  yet  been  fully  worked  out.  For 
instance,  we  are  still  in  doubt  as  to  the  value  to  be  attributed 
to  the  nitrogen  so  largely  disengaged  by  the  Buxton 
waters,  and  to  the  chloride  of  barium  which  is  distinctive 
of  those  of  Llangammarch. 

*  Cf.  Dr.  Frederick  T.  Roberts'  report  on  Llandrindod  Wells  in 
'  The  Climates  and  Baths  of  Great  Britain,'  p.  607. 


X. 

DIET  ANt)  HYGIENE  IN  THE  PROPHY- 
LAXIS AND  TREATMENT  OF  GOUT. 


CHAPTER  LVII. 
DIET  AND    GOUT. 

THE  INFLUENCE  OF  DIET  ON  THE  PREVALENCE  OF 
GOUT  AND  OF  GOUTINESS. 

As  stated  in  Chapter  IV.,  two  things  strike  us  very  forcibly 
in  contrasting  the  contemporary  history  of  gout  with  that 
of  the  last  century.  One  is  the  increase  in  the  numbers 
affected  ;  the  other  is  the  mitigation  of  the  forms  noticed. 

THE  INCREASED  FREQUENCY  OF  GOUTY  AFFECTIONS. 

Gout  is  essentially  a  disease  of  civilization.  This  is  a 
fact  written  large  in  the  history  of  most  nations.  We 
have  heard  little  of  its  prevalence  among  Spartans — and 
in  the  days  of  the  Republic,  Rome  seems  to  have  been 
exempt,  whilst  during  the  Empire  the  luxurious  habits 
of  living  made  it  a  growing  scourge,  even  women,  whose 
natural  tendency  to  it  is  less  than  that  of  men,  becoming 
largely  affected.  In  modern  times  we  have  the  testimony 
of  explorers  that  it  is  unknown  among  savage  races,  and 
only  observed  in  isolated  individuals  transplanted  into  the 
midst  of  civilization. 


520  INCREASED  FREQUENCY  OF  GOUTY  AFFECTIONS 

The  second  half  of  this  century  has  been  marked  by  an 
unprecedented  extension  of  the  luxuries  of  life  ;  the  law 
which  has  been  stated  would  suggest  a  corresponding 
increase  in  the  numbers  affected ;  and  such  is  the  result 
we  observe.  There  may  have  been  error  .of  judgment  on 
the  part  of  those  who  see  something  of  gout  in  almost 
every  patient.  In  itself,  over-anxiety  not  to  miss  the 
diagnosis  is  a  tolerably  sure  indication  that  the  real  disease 
has  been  too  often  met  with  and  sometimes  overlooked. 
Have  we  not  witnessed  the  same  tendency  during  the 
great  prevalence  of  influenza  ?  Influenza  was  wrongly 
diagnosed  as  present  very  much  in  proportion  to  the  pre- 
vailing frequency  of  the  affection.  Even  the  most  critical 
observers  will  probably  agree  in  recognising  not  only  an 
increased  prevalence  of  gout  and  goutiness  among  the 
upper  classes,  but  its  wider  extension  to  strata  previously 
less  affected. 

Gout  among  the  Masses — The  Poor  Man's  Gout.  —  In 
speaking  of  the  influence  of  social  status,  Sir  A.  Garrod 
inclines  to  regard  the  poor  man's  gout  as  one  connected 
especially  with  impeded  excretion,  whilst  the  rich  man's 
gout  would  be  due  mainly  to  increased  supply  and  accu- 
mulation of  uric  acid.  This  distinction  will  probably 
remain  true  always,  so  long  as  the  really  poor  are  with  us ; 
but  in  this  countr}^  at  least  it  is  tending  to  become  less 
absolute.  It  is  well  known  that  the  dietary  of  the  lower 
classes  has  undergone  considerable  improvement.  The 
enormous  importation  of  meat  at  a  relatively  low  price 
has  led  to  a  considerable  increase  per  head  in  its  consump- 
tion. The  well-to-do  take  probably  not  much  more  than 
they  used  to  consume,  and  paupers  or  the  very  poor  are 
probably  still  largely  debarred  from  a  meat  diet.  The 
increased  consumption  thus  falls  to  a  section  of  the  lower 
class  whom  circumstances  favour,  and  their  share  in  the 


THE  ATTENUATIONS  OF  GOUT  521 

increase  is  probably  in  excess  of  that  which  appears  in  the 
returns  calculated  per  head  of  total  population. 

What  is  true  of  meat  is  equally  true  of  most  other 
foods,  but  specially  of  saccharine  and  fatty  foods,  in  addi- 
tion to  eggs. 

THE  ATTENUATIONS  OF  GOUT. 

On  the  increased  prevalence  of  gouty  affections  among 
the  upper  classes  it  is  unnecessary  to  dwell.  The  most 
remarkable  features  are  :  (i)  The  lessened  frequency  of 
the  more  severe  manifestations  ;  (2)  the  milder  type  of  the 
acute  attack ;  and  (3)  the  greater  predominance  of  condi- 
tions which  may  be  described  as  'attenuations  of  gout,' 
or  '  goutiness,'  in  which  there  may  have  been  just  enough 
of  the  articular  trouble  to  identify  their  gouty  origin  and 
character,  but  which  for  the  rest  run  an  abarticular  course 
implicating  various  organs  and  functions,  and  specially  the 
nervous  system. 

For  these  changes  various  explanations  may  be  sug- 
gested. It  is  an  undoubted  fact  that  health  has  been 
more  of  a  study.  Even  the  gouty,  whose  memory  for 
their  past  suffering  is  particularly  short,  have  shown  less 
recklessness,  and  been  guided  in  some  degree  by  the 
enlightened  advice  of  physicians.  They  have,  as  a  class, 
attended  more  to  diet  and  to  hygiene.  The  total  absten- 
tion from  wine  in  favour  of  whisky,  which  has  been  largely 
practised,  has  probably  aided  the  result.  A  diminution 
has  occurred  in  the  severity  of  the  seizures.  The  benefit 
gained  has  in  some  measure  been  enjoyed  by  the  offspring, 
and  inherited  gout  has  probably  become  less  severe. 

To  these  influences  should  be  added  that  of  the  modern 
forms  of  medicinal  treatment.  Chemical  antidotes  have 
not  only  helped  to  reduce  the  severity  and  the  duration  of 
the  acute  attack,  but  cautiously  administered  during  periods 


522  THE  ATTENUATIONS  OF  GOUT 

of  freedom,  or  at  the  earliest  indications  of  a  return,'  have 
procured  many  a  respite  from  fits  which  otherwise  had 
been  unavoidable.  In  this  happy  result  the  systematic 
use  of  appropriate  mineral  waters,  and  periodical  visits  to 
the  medicinal  springs,  have  doubtless  had  a  share. 

Meanwhile,  however,  the  great  stress  thrown  upon  the 
nervous  system  by  the  peculiarities  of  modern  life  seems 
to  have  brought  about  increased  susceptibility  to  the  in- 
fluence of  the  irritating  material,  and  in  a  fresh  direction. 
The  great  toe  has  ceased  to  be  in  many  cases  the  seat  of 
least  resistance,  weaker  spots  having  developed.  In  other 
words,  a  dose  of  poison  hardly  sufficient  to  determine  a 
true  podagra  has  been  enough  to  call  forth  elsewhere  less 
sharply-defined  manifestations.  In  this  way,  whilst  the 
causes  leading  to  gout  have  multiplied,  and  the  number  of 
those  affected  increased,  the  major  attacks  of  the  disease 
have  diminished  in  frequency,  and  the  minor  gouty  ail- 
ments are  more  and  more  coming  to  the  front. 

THE  INFLUENCE  OF  DIET  IN  THE  PRODUCTION 
OF  GOUT. 

A  competent  knowledge  of  the  influence  of  diet  on  the 
production  of  gout  would  help  us  to  guard  against  the 
affection.  Our  endeavours  for  its  relief  would  also  be 
better  guided,  although  the  methods  of  prophylaxis  and 
those  of  treatment  are  not  identical.  Gout  is  commonly 
acquired  with  the  help  of  a  sound  stomach,  but,  for  its 
cure,  a  healthy  digestion  is  no  longer  at  command,  and  in 
daily  practice  dieting  the  gouty  patient  is  as  difficult  as  it 
is  important.  It  will  be  well,  then,  to  deal  with  the  setio- 
logical  and  with  the  therapeutical  aspects  of  dietetics  in 
succession,  beginning  with  the  former. 

The  derivation  of  gout  from  habitual  excess  in  alimenta- 
tion was  well  known  to  the  ancients,  and  we  still  hold  to 


THE  ETIOLOGICAL  INFLUENCE  OF  DIET         523 

the  same  broad,  common-sense  view  of  the  subject.  But 
the  attempt  to  define  the  principles  of  diet  on  the  hues 
of  the  uric  acid  theory  has  led  to  a  conflict  of  opinions 
which  suggests  that  we  lack  either  sufficient  knowledge,  or 
sufficient  regard  for  that  which  is  definitely  known.  In 
gout,  more  than  elsewhere,  because  of  its  idiosyncrasies, 
we  should  beware  of  dogmatism.  Gout  is  undoubtedly 
prevented  by  starvation ;  yet  it  does  not  follow  that  it 
may  be  cured  on  that  plan.  Gout  may  also  be  prevented 
by  strict  avoidance  of  animal  food.  This  does  not  prove 
that  it  need  in  every  case  be  treated  on  vegetarian  prin- 
ciples. Again,  although  gout  may  fail  to  attack  some  of 
those  whose  diet  is  exclusively  animal,  we  are  not  warranted 
in  prescribing  meat  as  the  diet  for  gout. 

Each  case  should  be  studied  on  its  own  merits  ;  but  it 
is  essential  that  we  should  grasp  the  main  principles 
which  underlie  all  individual  variations. 

'  Great  eaters  are  liable  to  gout,  and  of  these  the  costive 
more  especially.  Eating  as  they  used  to  eat  when  in  full 
exercise,  their  digestion  is  naturally  impaired.  Even  in 
these  cases  simple  gluttony  and  the  free  use  of  food, 
although  common  incentives,  by  no  means  so  frequently 
pave  the  way  for  gout  as  reckless  and  inordinate  drinking.' 
In  these  lines  of  Sydenham  is  compressed  the  greater 
part  of  our  practical  knowledge.  Neither  the  quality  of 
food  nor  its  quantity  do  so  much  harm  as  the  fact  that 
it  is  unearned  by  muscular  exertion.  Mental  work  is  hungry 
work ;  but  it  does  not  fulfil  the  letter  of  the  law  that 
we  shall  earn  our  bread  by  the  sweat  of  our  brow.  The 
idea  that  close  study  is  productive  of  gout  is  probably 
erroneous.  Intellectual  labour  is  not  harmful  in  itself, 
but  only  in  the  measure  in  which  it  excludes  the  needful 
muscular  work,  and  the  tonic  influence  of  an  outdoor  life. 

The  second  factor  noted  by  Sydenham  is  constipation, 


524  THE  ETIOLOGICAL  INFLUENCE  OF  DIET 

by  which  we  may  understand  inactivity  of  the  Hver  as 
well  as  of  the  intestine. 

A  third  and  prominent  influence  is  that  of  the  impaired 
digestion,  to  which  we  may  trace  the  acidity  of  the  gouty 
state. 

The  fourth  factor  is  the  abuse  of  alcohol,  most  active  for 
harm  when  combined  with  excess  in  alimentation,  and 
co-operating  with  the  latter  in  checking  the  energy  of 
metabolism. 

All  these  are  acquired  facts,  but  their  mode  of  operation 
is  a  mystery.  By  what  mechanism  is  gout  produced  ? 
The  end  product  being  an  excess  of  insoluble  urate, 
research  has  been  steadily  devoted  to  tracing  the  patho- 
logical history  of  uric  acid,  with  results  to  which  we  shall 
presently  allude. 

The  broad  conclusions  to  be  drawn  from  Sydenham's 
observations  are  that  the  failure  of  the  digesting  and 
assimilating  functions  arises  from  their  inadequacy  to  deal 
with  the  relative  surfeit  of  food  ;  and  that  the  food  which 
is  strength  to  the  healthy  man  hecomes  poison  to  the  gouty. 
Two  questions  are  now  before  us  :  (i)  What  is  the  poison? 
(2)  Which  is  the  food  which  supplies  it  ? 

If,  as  alleged,  the  offending  substance  is  uric  acid,  either 
introduced  as  such,  or  subsequently  derived  from  food,  meat 
would  be  its  most  plentiful  source.  We  are  not  sure, 
however,  that  uric  acid  is  not  merely  a  by-product  in  gout, 
and  that  the  more  active  agents  are  not  those  which  escape 
our  notice  owing  to  their  greater  solubility.  The  ptomaines 
and  leucomaines  are  types  of  the  substances  to  which  we 
allude,  and  their  chief  source  is  again  animal  food. 


CHAPTER  LVIII. 

THE    VARIOUS   CONSTITUENTS    OF   FOOD    IN 

THEIR  RELATION  TO  NUTRITION 

AND  TO  GOUT. 

In  addition  to  the  water  and  to  the  mineral  and  organic 
salts  which  they  contain,  our  foods  consist  of  nitrogenous 
and  of  7ton-nitrogenous  principles ;  and  the  latter  are  of 
two  kinds — hydro-carbons  (fats)  and  carbo-hydrates  (starches 
and  sugars). 

The  Non-nitrogenous  Principles. — It  is  chemically  impos- 
sible that  these  bodies  should,  independently  of  others, 
give  rise  to  any  uric  acid  when  introduced  into  the 
economy  as  food ;  and  this  fact  has  been  amply  illustrated 
by  experiment.  Since,  however,  they  cannot  sustain  life 
without  additional  supplies  of  nitrogenous  substances, 
their  suitability  as  articles  of  diet  in  gout  is  not  a  self- 
evident  proposition. 

The  Nitrogenous  Principles. — ^These  are  the  generators 
of  urea,  and  indirectly  of  uric  acid  also.  It  is  now  amply 
proved  that  their  consumption  on  a  large  scale  is  followed 
by  an  increased  production  of  uric  acid,  and  that  the 
latter  diminishes  when  the  supply  is  restricted.  There 
is  also  no  doubt  that  the  increase  in  uric  acid  occurs  in 
connection  with  the  consumption  of  vegetable  albumens, 
as  well  as  with  that  of  animal  albumens,  although  the 
resulting  amount  of  uric  acid  need  not  be,  weight  for 
weight,  the  same  in  both  cases. 


526  FOOD  IN  RELATION  TO  NUTRITION  AND  TO  GOUT 

Many  of  our  food-stuffs  contain  all  three  principles ; 
others,  two  out  of  the  three.  The  following  table  shows 
the  proportion  of  the  nitrogenous  constituents  of  some  of 
the  more  usual  articles  of  diet  : 

Average  Percentage  of  ALBUMiNom  Matters  in  Various 

FOOD-STUFFS 
(compiled    by   sir   W.    ROBERTS    FROM    PAVY   AND    KONIG). 

Animal. 


Per  cent. 

Butcher's  meat     - 

-     19 

Fowl         -             -             -            - 

-     20 

Game        .             .             -            - 

-      22 

Fish          .... 

-       17 

Eggs        .            -            -            - 

-       13 

Milk         .            -            -            - 

-      4 

Cheese      -             -             -             - 

-     30 

Vegetable. 

Per  cent. 

Bread            -             -             -             - 

8 

Oatmeal       .             -             -             - 

12 

Rice              ...             - 

6 

Green  peas  -             -             -             - 

6 

Potatoes       -             -             -            . 

2 

Carrots  and  turnips 

T  to  2 

Green  vegetables  and  salad 

I  to  2 

Fresh  fruit  (excluding  nuts) 

-     o'5  to  I 

When  restricted  to  starchy  food-stuffs,  such  as  potatoes, 
greens,  rice,  bread,  etc.,  we  can  still  obtain  a  sufficiency 
of  nitrogen,  but  the  large  bulk  of  food  from  which  it  has 
to  be  extracted  will  tax  our  powers  of  digestion.  If, 
conversely,  we  were  dependent  wholly  upon  meat,  the 
non-nitrogenous  elements  could  only  be  found  by  using  a 
comparatively  large  weight  of  it.  This  arrangement  is 
generally  regarded  as  unsuitable  for  gout,  whilst  that  first 
mentioned,  though  not  desirable,  might  perhaps  stimulate 


VARIOUS  FOOD-STUFFS  IN  GOUT  AND  GOUTINESS  527 

into  activity  the  languid  powers  of  digestion  and  of 
assimilation,  and  lessen  the  torpor  which  arises  from 
never-failing  supplies  of  the  easier  combinations  of  food. 

THE  BEHAVIOUR    OF  THE  VARIOUS  FOOD-STUFFS  IN 
GOUT  AND  GOUTINESS. 

The  Carbo-hydrates. — For  the  ordinary  gouty  subject, 
free  from  glycosuria  and  from  obesity,  starchy  food  in 
moderation  is  not  in  itself  harmful.  The  glucose  to 
which  it  gives  rise  is  relatively  well  borne.  The  same 
cannot  be  said  of  cane-sugar,  much  more  prone  to  fer- 
ment, and  to  liberate  lactic  acid.  The  gouty  dyspeptic 
is  often  absolutely  intolerant  of  starch  and  of  saccharose, 
even  when  taken  apart  from  other  food.  Others,  whose 
digestion  is  but  slightly  impaired,  will  be  able  to  use  them 
with  discretion. 

Injudicious  admixture  with  various  indigestibles  is  really 
answerable  for  much  of  the  fermentation  of  starches,  and 
particularly  for  that  of  sugar.  Acid  wines,  acid  fruit, 
and  elaborate  sweet  dishes,  are  specially  obnoxious  in  this 
respect.  Preserved  fruit  and  jams,  being  heavily  loaded 
with  cane-sugar,  are  most  apt  to  ferment. 

Fats  are  to  be  used  sparingly  in  gout.  Here,  again, 
great  differences  occur  between  individual  subjects. 
Putting  aside  the  dyspeptics  who  are  quite  intolerant, 
some  will  take  fat  in  moderation  with  impunity,  others 
are  easily  upset.  Of  all  forms  of  fat,  browned  fat  is  the 
most  difficult  to  digest  (Duckworth),  and  for  this  reason 
fried  iish  and  bacon  are  best  avoided.  According  to 
Ebstein,  there  is  no  evidence  that  a  moderate  use  of  fat 
favours    the    production    of  gout.*      Great    importance 

*  The  supposed  detrimental  action  of  fat  in  gout  is  discussed  by 
Ebstein,  who  refers  to  the  experiments  of  Meissner  and  R.  Koch  on 
the  appearance  of  succinic  acid  in  the  urine  after  ingestion  of  calcium 


528  VARIOUS  FOOD-STUFFS  IN  GOUT  AND  GOUTINESS 

attaches  to  its  use  as  a  guarantee  that  the  organism  shall 
not  suffer  in  its  capacity  for  exertion  and  resistance. 

Ebstein  permits  meat  and  a  corresponding  amount  of 
fat  in  the  treatment  of  obesity  and  of  gout,  but  limits  the 
carbo-hydrates  to  a  minimum.  The  carbo-hydrates  save 
the  albumen  from  complete  destruction,  part  of  it  being 
stored  as  fat.  Fats  likewise  save  albumens,  but  in  a  far 
less  degree  than  carbo-hydrates  :  '  That  part  of  the 
albumen  which  is  decomposed  with  the  corresponding  use 
of  fat  is  decomposed  completely,  and  does  not  remain 
in  the  body  in  an  intermediate  state  as  fat.  Wherefore 
fat  lessens  the  need  for  nourishment  by  protecting  the 
systemic  aliumen,  as  Hippocrates  was  already  aware.'* 

The  increased  need  for  food  peculiar  to  a  pure  meat 
diet  ceases,  and  the  patient  puts  up  with  the  curtailment 
of  the  excess  of  albuminates,  and  '  falls  back  on  the  right 
quantity  of  food,'  so  long  as  a  suitable  amount  of  fat  is 
added  to  his  diet.  For  this  reason  Ebstein  allows  fat 
together  with  the  albuminates,  whereas  80  to  100  grammes 
of  bread  should  be  the  limit  of  the  carbo-hydrate  supply. 
Spinach,  cauliflower,  and  red  cabbage  are  the  vegetables 
permitted  in  moderation  ;  turnips,  carrots,  and  beets  are 
not  allowed. 

The  7ntrogenous  foods  are  chiefly  represented  by  meat 
and  fish,  and  by  cheese.     The  leguminous  vegetables  also 

malate  and  of  asparagin,  together  with  large  quantities  of  alkaline 
urates.  The  succinic  acid  appeared  only  after  the  ingestion  of  a 
surplus  of  fat  ;  but  the  large  quantities  used  were  out  of  all  proportion 
to  the  ordinary  consumption  of  fat. 

*  'The  Nature  and  Treatment  of  Gout,'  by  W.  Ebstein,  M.D., 
Professor  of  Medicine  and  Director  of  the  Medical  Klinik  in  the 
University  of  Gottingen.  Authorized  translation  by  J.  E.  Burton, 
L.R.C.P.  Lond.,  M.R.C.S.,  surgeon  to  the  Hospital  for  Women,  Liver- 
pool ;  vice-president  of  the  Liverpool  Medical  Institution.  London  : 
Bailliere,  Tindall  and  Cox,  1886.     Cf.  p.  164. 


VARIOUS  FOOD-STUFFS  IN  GOUT  AND  GOUTINESS  529 

contain  a  rather  large  proportion  of  nitrogen.     The  ques- 
,  tions  relating  to  meat  will  be  discussed  separately. 

Vegetables. — The  slow  digestion  of  vegetable  fibre,  the 
acidity  of  the  vegetable  juices,  and  the  fermentation 
which  they  undergo,  are  responsible  for  much  dyspepsia. 
Uncooked  vegetables  are  inadmissible  ;  and  when  vege- 
tables are  taken  in  conjunction  with  other  food,  they 
should  be  of  the  lighter  kind  only,  free  from  fibre,  and 
faultlessly  prepared.  Much  might  be  done  to  render  our 
vegetable  alimentation  more  palatable,  as  well  as  easier  of 
digestion. 

In  this  country  vegetables  are  regarded  as  mere  adjuncts 
to  meat ;  in  France  they  are  made  to  be  a  relish  in  them- 
selves, fit  to  be  enjoyed  as  a  separate  dish,  when  no  meat 
is  on  the  table.  We  might  do  worse  than  follow  the 
example  of  a  Devonshire  father,  who  made  a  rule  that 
vegetables  should  be  served  first,  lest  the  children  should 
eat  too  much  meat. , 

Fruit  is  another  source  of  acidity,  the  acid  gastric 
fermentation  coinciding  with  the  alkalizing  effect  on  the 
blood  of  the  formation  of  carbonates  from  the  vegetable 
acids  themselves.  Widely  different  notions  have  been 
expressed  as  to  the  effect  of  fruit  on  gouty  subjects.  Sir 
Andrew  Clark  was  strongly  of  opinion  that  all  fruit  was 
harmful  and  promoted  gouty  symptoms.  Others,  on  the 
contrary,  see  in  its  proper  use  a  direct  corrective.  Much 
depends  upon  the  variety  and  upon  the  quality  of  the 
fruit,  and  much  also  upon  idiosyncrasy. 

It  is  an  elementary  precaution  to  avoid  in  gout  all 
indigestible  fruit,  and  to  use  even  stewed  fruit  sparingly. 
The  late  Dr.  Milner  Fothergill  pointed  out  that  stewed 
fruit  might  be  used  harmlessly  if  a  proportion  of  bicar- 
bonate of  soda  were  added  to  each  supply. 

Among  the  varieties   of  fruit  which   may  be  allowed, 

34 


530  VARIOUS  FOOD-STUFFS  IN  GOUT  AND  GOUTINESS 

Sir  A.  Garrod  mentions  strawberries  in  small  quantities, 
grapes,  oranges,  and  other  succulent  fruits.  He  dis- 
approves of  all  stone  fruits,  and  of  apples  and  pears 
unless  baked. 

We  shall  revert,  in  connection  with  alcohol,  to  the 
question  of  cider  and  of  the  virtues  of  apples. 

Water  and  the  Mineral  Salts. — The  value  of  frequent 
draughts  of  water,  and  especially  of  hot  water,  has  been 
sufficiently  dwelt  upon  in  the  therapeutical  section.  Hot 
water  with  meals  agrees  remarkably  with  some  stomachs. 
The  systematic  water-drinking  to  which  we  refer  is  quite 
distinct  from  this  practice,  and  should  be  reserved  for 
fasting  intervals,  when  there  is  no  digestion  to  disturb. 
The  objectionable  hardness  of  many  waters,  which  is  re- 
garded by  some  as  prejudicial  in  gout,  may  be  reduced 
by  previous  boiling,  or  simple  aerated  water  may  be 
substituted. 

Chloride  of  sodimn  is  the  most  important  of  the  indis- 
pensable mineral  salts.  The  majority  of  the  latter  are 
conveyed  in  sufficient  amount  in  the  food  and  in  drinking- 
water.  Common  salt  itself  is  contained  in  food,  and 
added  to  it  in  cooking.  We  have  already  dwelt  upon  the 
therapeutic  aspects  of  the  salt  question.  The  consump- 
tion of  salt  is  just  one  of  those  small  matters  which  may 
tell  by  constant  repetition.  Sir  W.  Roberts,  who  recom- 
mends the  lithuric  patient  to  take  as  much  salt  as  the 
palate  will  tolerate,  would  have  the  gouty  use  it  most 
sparingly.  There  is  great  wisdom  in  this  recommendation, 
the  appetite  hardly  needing  to  be  whetted  in  the  average 
gouty  patient  ;  it  is  one,  however,  difficult  to  carry  out, 
especially  under  the  French  system,  so  much  depending 
upon  the  action  of  the  cook. 


CHAPTER  LIX. 

THE  INFLUENCE  OF  DIET  ON  LEUCOCYTOSIS, 
AND  ON  THE  RELATIVE  EXCRETION  OF 
NITROGEN,  OF  UREA,  AND  OF 
URIC  ACID. 

Much  attention  has  been  directed  to  the  study  of  the 
effect  of  various  kinds  of  diet  upon  the  nitrogenous  excreta, 
and  in  particular  of  uric  acid,  since  Horbaczewski's  dis- 
covery of  the  part  played  by  the  nuclein  of  leucocytes  in 
the  production  of  the  latter.  The  following  table  embodies 
Horbaczewski's  own  experimental  results  : 


Tabulated  Results  of  Horbaczewski's  Observations  on  the 
Number  of  Leucocytes  and  on  the  Amount  of  Uric  Acid 
excreted  respectively  after  Eighteen  Hours'  Fasting, 
AND  Five  Hours  after  a  Nitrogenous  Meal  (A,  A'),  and 
AFTER  A  Non-nitrogenous  Meal  (B,  B').* 

A. — Fasting. 


Leucocytes 

C.C.  urine 

Uric  acid 

Total  nitrogen 

Cases. 

counted  after 

(lyih  and  i8th 

(milli- 

(milli- 

i8 hours'  fast. 

hour). 

gram  ines). 

grammes). 

I 

4,500 

170 

39'9 

1,034 

2 

4,750 

50 

42-5 

642 

3 

5,002 

120 

496 

1,056 

4 

9,950 

50 

57-2 

756 

5 

5,700 

160 

33'3 

463 

*  From  Levison,  loc.  cit.,  pp.  15,  16. 


532     THE  INFLUENCE  OF  DIET  ON  LEUCOCYTOSIS 


A'  {Same  Cases). — A/ier  a  Meal  of  Meat ^  Bread.,  Butter.,  Beer,  etc. 


Leucocytes  counted 
5  hours  after  meal. 

C.C.  urine 

(4th  and  5th 

hour). 

Uric  acid  (milli- 
grammes). 

Total  nitro- 
gen (milli- 
grammes). 

7,250  =   +6ri% 

7,500    =    +57-9 

7,744  =   +54-8 

14,900  =   +497 

7,700  =   -f35-i 

340 

85 
380 
260 

85 

148-1    =    +271-0% 
II7'3   =    +i76'o 
143-2  =   +i88-o 
106-0  =   +  86-0 
102-0  =   +2060 

1,445 
1,014 
1,838 

1,445 
925 

B. — Fasting. 


Leucocytes 

C.C.  urine 

Uric  acid 

Total  nitrogen 

Cases. 

counted  after 

(17th  and  i8th 

(milli- 

(miUi- 

18  hours'  fast. 

hour). 

grammes). 

grammes). 

I 

4,500 

170 

39"9 

1,034 

2 

4,750 

50 

42-5 

642 

3 

5,002 

120 

49-6 

1,056 

5 

5,700 

160 

33'3 

463 

B'  (Same  Cases). — After  a  Meal  of  Vegetable  Food  only. 


Leucocytes  counted 
5  hours  after  meal. 

C.C.  urine 

(4th  and  5th 

hour). 

Uric  acid  (milli- 
grammes). 

Total  nitro- 
gen (milli- 
grammes). 

5,900    =    +23-1% 
4,900   =    +    3-1 
5,050   =    +   0-95 
5,850    =    +    2-5 

95 

55 
280 
290 

77-4    =    +94-0% 
52-9    =    +24-5 

59"3  =   +i9'5 
42-3  =  +27-0 

869 

793 

1,159 

1,086 

The  tables  A'  and  B'  show  a  decided  correspondence 
between  the  increase  in  the  number  of  leucocytes  and  that 
in  the  amount  of  uric  acid  after  a  meal,  whilst  pointing  to 
individual  peculiarities  in  the  proportion  for  each  case. 
They  further  show  that  during  the  fourth  and  the  lifth 
hour  after  a  meal  the  increase  under  both  heads  is  much 


After  3  days' 
animal  diet 
(grammes). 

After  3  days' 

vegetable  diet 

(grammes). 

24-4465 

IO-92I7 

47-3882 

19-8082 

22-II3 

9-2432 

0-859 

0-791 

0-2863 

0-2637 

I  :  55-16 

I  :  25-04 

THE  INFLUENCE  OF  DIET  ON  URIC  ACID  533 

less  in  the  case  of  a  non-nitrogenous  than  in  that  of  a 
nitrogenous  meal. 

No  conclusion  could,  however,  be  drawn  from  them  as 
to  the  total  excretion  for  twenty-four  hours.  We  owe  to 
Bleibtreu  and  Schultze*  a  valuable  contribution  on  this 
point.  These  observers  determined  their  own  total  excre- 
tion of  uric  acid  for  twenty-four  hours  under  vegetable 
and  under  animal  diet.  Bleibtreu's  results  were  as 
follows  : 


Total  nitrogen  excreted 

Urea      

Nitrogen  in  the  urea  ... 
Uric  acid 

Nitrogen  in  the  uric  acid 
Proportion  of  urea  to  uric  acid 
Proportion  of  nitrogen  of  urea 
to  nitrogen  of  uric  acid      ...     i  :  73-6  i  :  35*05 

Schultze,  whose  habitual  excretion  of  urea  per  diem  was 
carefully  estimated  at  31 '647  to  33*8549  grammes,  and  of 
uric  acid  at  0-836  to  0*844  gramme,  reached,  on  succes- 
sive days  of  an  animal  diet,  the  following  amounts  : 

Urea 

Uric  acid ... 

It  is  abundantly  proved  by  these  and  other  observations 
(Hirschfeld,  Stadthagen,  and  others)  that  whereas  the  urea 
excretion  rises  with  almost  mathematical  accuracy  with  the 
amount  of  proteids  taken,  the  oscillations  in  the  uric  acid 
excreted  are  much  more  limited,  and  are  not  regulated  by 
the  diet.     This  is  strictly  confirmed  by  Dapper  {cf.  p.  100). 

A  valuable   counter-proof  was    supplied    by   Busquet."f* 

*  Pfluger's  'Archiv.,'  Bd.  45,  p.  401  (Levison,  /oc.  cit.,  p.  17). 
t  Revue  de  Medecine^  1892,  p.  572  (Levison,  loc.  cit.,  p.  19). 


Grammes. 

Grammes. 

Grammes. 

58-89 

67-23 

73"65 

1-3886 

1-270 

1-473 

534     THE  INFLUENCE  OF  DIET  ON  LEUCOCYTOSIS 

The  case  was  that  of  a  chemist,  who,  by  low  diet, 
reduced  his  weight  in  the  space  of  eighteen  months  from 
107  to  74'5  kilogrammes,  and  his  daily  urea  from  28  to 
10  grammes.  Meanwhile,  the  simultaneous  determinations 
of  uric  acid  made  every  day  during  the  whole  period 
yielded  an  almost  constant  figure  (o'6  gramme),  not  falUng 
below  0*4  gramme,  and  ultimately  rising  to  i"02. 

After  injection  of  0*75  gramme  nuclein,  a  rabbit  passed 
25"8  milligrammes  of  uric  acid  instead  of  the  normal  daily 
average  of  7  to  8  milligrammes. 

To  test  Maruss's  observation  that,  after  decreasing 
during  the  twelve  hours  which  follow  a  meal,  the  uric  acid 
excretion  remains  stationary  for  fourteen  hours,  a  man 
was  given  5*5  grammes  nuclein  suspended  in  water  eighteen 
hours  after  a  meal,  when  the  excreted  uric  acid  amounted 
at  that  time  for  two  hours  to  46*8  milligrammes : 

Milligrammes. 
During  the  first  period  of  2  hours  after  the  nuclein  was 

taken  the  amount  was    ...         46*9 

During  the  second  period  of  2  hours  the  amount  was  ...     647 
During  the  third  period  of  2  hours  the  amount  was    ...     93'6 

The  delay  is  explained  by  the  slowly  digesting  nature  of 
nuclein. 

These  experiments  are  almost  conclusive  in  pointing 
to  the  leucocytosis  which  accompanies  digestion  as  the 
source  of  the  rise  in  the  uric  acid  tide  after  meals. 

This  conclusion  is  supported  by  much  collateral  evidence, 
which  may  be  summed  up  in  the  statement  that  an 
increased  uric  acid  excretion  goes  hand-in-hand  with  an 
increase  in  the  number  of  leucocytes — whether  physio- 
logical, as  in  infancy  and  childhood  (Martin  und  Ruge  and 
Pfeiffer),  and  after  ingestion  of  nuclein  (Horbaczewski); 
or  pathological,  as  in  leucocythsemia  (Laache,  Bartels, 
Bohland  und  Schurz,  Stadthagen,  and  others) ;  in  pneu- 


THE  INFLUENCE  OF  DIET  ON  LEUCOCYTOSIS     535 

monia  and  cancer  and  extensive  burns,  and  after  pilo- 
carpin  (Horbaczewski),  after  alcohol  (Chittenden,  Camerer, 
Levison),  and  after  unusual  physical  exertion  (Levison). 

The  same  rule  is  confirmed  by  the  diminution  brought 
about  both  in  the  number  of  leucocytes  and  in  the  amount 
of  uric  acid  by  quinine  and  atropine.  The  only  exception 
relates  to  the  effects  of  antipyrin  and  of  antifebrin,  which 
produce  an  increase  in  the  leucocytes  and  a  reduction  in 
the  uric  acid,  presumably  because  under  their  influence 
the  leucocytes  may  enjoy  an  unusual  vitality,  instead  of 
breaking  up  early,  as  after  pilocarpin,  which  also  leads  to 
splenic  enlargement  and  karyokinesis  in  the  lymphatics  of 
the  spleen. 

Conclusions. — We  should  be  taking  too  limited  a  view 
were  we  to  connect  the  production  of  uric  acid  with  the 
destruction  of  leucocytes  alone.  Some  arguments  which 
have  been  brought  forward  support  with  almost  equal 
force  the  conclusion  that  uric  acid  is  derived  from  dis- 
integrative and  metabolic  changes  in  the  totality  of  the 
organism — changes  which,  as  stated  by  Levison,  are  in- 
fluenced by  alimentation,  but  not  in  the  proportion  of  the 
nitrogenous  ingesta,  whilst  the  production  of  urea  is 
strictly  proportionate  to  the  latter.  According  to  this 
view  the  individual  uric  acid  production  would  be  for 
each  subject  a  personal  factor,  remaining  fairly  constant 
on  the  whole,  but  subject  to  minor  variations  with  each 
oscillation  of  the  metabolism. 


CHAPTER  LX. 

THE  VEGETARIAN  TREATMENT  AND  THE 
'MEAT'  TREATMENT  OF  GOUT. 

The  labours  which  have  been  devoted  of  late  years  to  the 
theoretical  study  of  gout  have  led  to  some  strange  con- 
clusions in  connection  with  the  practical  questions  of  diet. 
We  are  assured  by  one  authority  that  vegetarianism  is 
the  cure  for  gout,  by  another  that  butcher's  meat  is  the 
true  and  successful  remedy.  This  contradiction  would 
almost  suggest  that  the  nature  of  the  diet  was  a  matter  of 
indifference.  It  reminds  us  most  forcibly  that  all  cases 
are  not  to  be  treated  alike  ;  it  enables  us  also  to  criticise 
without  invidiousness  both  conflicting  principles  of  treat- 
ment. 

Both  methods  lean  partly  upon  theory.  Vegetarianism 
may  be  regarded  as  the  logical  outcome  in  dietetics  of  the 
wic  acid  theory  of  gout.  The  meat  treatment  finds  support 
in  the  experimental  evidence  that  an  increased  consump- 
tion of  meat  leads  to  an  increase  of  the  output  of  urea 
rather  than  of  uric  acid.  These  recent  experiments  have 
been  described  in  Chapters  XIV.  and  LIX.  Their  re- 
sults are  essentially  identical  with  those  obtained  long  ago 
by  Lehmann,  who  found  that  the  excretion  of  uric  acid 
and  of  urea  varied  in  the  following  proportions  : 

Under  a  mixed  diet  -  -  -  -     i  to  29 

Under  an  animal  diet  -  -  -     i  to  38 

Under  a  vegetable  diet        -  -  -     i  to  22 


THE  VEGETARIAN  TREATMENT  537 

The  physiological  law  which  is  thus  clearly  made  out 
can  hardly  be  used  as  the  basis  of  a  treatment  of  gout, 
unless  it  be  assumed  that  excess  of  uric  acid  is  the  essence 
of  gout,  and  of  this  we  do  not  yet  possess  sufficient 
evidence. 

Whilst  both  methods  are  more  or  less  directly  in  touch 
with  the  uric  acid  theory,  there  is  an  apparent  contradiction 
between  the  views  put  forth  by  Dr.  Haig  and  the  law  that  a 
vegetable  diet  gives  a  higher  excretion  of  uric  acid  relatively 
to  urea.  For  this  discrepancy  Haig  offers  an  explanation. 
He  points  out*  that  the  relatively  diminished  excretion  of 
uric  acid  under  animal  diet  is  due  to  raised  acidity,  this 
being  the  early  result ;  but  that  in  course  of  time  the  uric 
acid,  meanwhile  stored  up,  would  be  excreted  again,  and 
would  then  be  greatly  in  excess  ;  and  that  the  relatively 
increased  excretion  under  vegetable  diet  is  due  to  the 
lowering  of  the  acidity,  which  enables  more  uric  acid  to 
pass  out.  This  increased  excretion  would  gradual^  fall 
to  the  normal  level  after  the  stores  of  uric  acid  had  been 
exhausted.  As  a  fact,  the  production  never  varies  much 
from  the  proportion  i  to  33  or  i  to  35. 

Dr.  Mortimer  Granville  does  not  regard  the  danger  of 
increasing  the  acidity  as  an  objection  to  the  supply  of 
butcher's  meat.  Assuming  the  normal  urinary  acidity  to 
range  from  2*5  to  3'o  pro  mille,  Granville  finds  in  500 
gouty  urines  an  average  of  3*285  :  but  58  per  cent,  of 
the  cases  fall  short  of  this  average,  and  4i"5  per  cent, 
exceed  it,  thus  showing  that  the  urine  in  gout  may  be  less 
acid  than  that  in  health.  These  results  were  obtained  in 
spite  of  an  absolute  avoidance  of  the  alkaline  treatment. 
The  argument  thus  derived  from  the  degree  of  acidity  is 
perhaps  open  to  the  objection  that  the  urine  does  not 

*  Br/t.  Med.  Journal,  vol.  ii.,  1888,  p.  10. 


538  THE   VEGETARIAN  TREATMENT 

necessarily  contain  the  full  proportion  of  acid  present  in 
the  system. 

Haig's  work*  gives  a  table  of  the  quantities  of  uric  acid 
which  he  has  extracted  from  some  of  the  animal  tissues 
commonly  used  for  food  :  Mutton  (cold  roast  leg)  con- 
tained -016  per  cent.  ;  veal  (cutlet),  '049 ;  beef  (cold 
sirloin),  -016;  beef-tea  (treated  raw),  "019;  meat-juice, 
•697  ;  meat  extract,  '883. 

Believing  that  the  excess  of  uric  acid  in  gout  is  derived 
from  these  and  from  analogous  sources,  Haig  sums  up  the 
dietetic  part  of  his  treatment  thus  :  '  The  whole  point  of 
the  diet  treatment  of  uric  acid  disease  is  to  cut  out  the 
butcher,  and  hve  by  the  baker,  the  dairyman,  and  the 
fruiterer ;  and  if  these  things  are  well  taken,  urea  will  be 
kept  at  3  grains  per  lb.  of  body  weight  (corresponding  to 
a  formation  of  about  i  grain  of  uric  acid  for  12  lb.  of 
body  weight),  without  the  addition  of  eggs.' 

The  opposition  between  the  arguments  adduced  is  not 
less  striking  than  that  of  the  methods  which  they  seek  to 
support.  We  are  induced  to  look  farther  afield  for  a 
rational  explanation  of  the  favourable  results  reported 
from  both  sides,  and  we  find  a  plausible  suggestion  in 
Sydenham's  view,  that  gout  is  dyspepsia :  '  The  more 
closely  I  have  thought  upon  gout,  the  more  I  have 
referred  it  to  indigestion.'  Any  relief  to  the  dyspepsia 
would  be  some  relief  to  the  gout. 

Both  methods  under  discussion  are  remedies  for 
dyspepsia  —  the  one  a  radical,  the  other  a  palliative 
remedy.  To  simplify  the  diet  to  little  besides  meat  would 
be  to  lessen  the  labour  of  the  stomach,  whilst  ensuring 
proper  support.  To  give  up  all  meat,  and  learn  to  live 
and  thrive  on  vegetable  and  milk  food,  would  be  to 
conquer  at  one  stroke  dyspepsia  and  the  gout. 

*  Cf.  loc.  cif.,  p.  355. 


THE  TREATMENT  BY  MEAT  DIET  539 

THE  TREATMENT  BY  MEAT  DIET. 

Whilst  recognising  the  advantages  of  a  meat  diet  in 
cases  of  dyspepsia  where  starches,  sugars,  and  fats  are 
apt  to  set  up  acid  fermentation,  we  cannot  overlook  the 
frequent  instances  of  goutiness  in  which  meat  is  distinctly 
obnoxious  ;  neither  can  we  put  aside  the  accumulated 
clinical  evidence  which  shows  that  a  habitual  excess  of 
animal  food  favours  the  development  of  gout.  A  large 
consumption  of  meat  may  be  kept  up  for  long  periods 
without  giving  rise  to  gout,  especially  if  sufficient  exercise 
be  taken  ;  and  great  moderation  in  animal  food  is  not 
always  rewarded  by  immunity.  Again,  absolute  proof  is 
wanting  that  it  is  the  nitrogen  in  meat  which  produces 
the  gout,  though  it  undeniably  increases  the  production  of 
uric  acid ;  and  it  is  equally  unproved  that  carbo-hydrates 
and  fats  do  not  take  a  share  in  the  production  of  gout, 
although  they  are  quite  unable  to  supply  any  uric  acid. 

Nevertheless,  when  all  this  is  granted,  the  broad  clinical 
facts  remain,  that  acquired  gout  is  most  common  in  those 
whose  indulgence  in  animal  food  is  excessive,  and  that  it 
is,  practically  speaking,  unknown  among  races  who  do  not 
consume  meat,  and  in  persons  who  for  a  long  time  have 
been  strict  vegetarians. 

In  this  country  gout  is  usually  acquired,  with  the  help 
of  a  good  digestion,  and  of  just  exercise  enough  to  favour 
an  appetite,  on  plentiful  meat-supplies,  coupled  with  an 
abundance  of  every  other  kind  of  food,  and  on  wine  or  beer. 
This  is  the  history  of  the  well-to-do  and  of  their  butlers. 

Among  the  lower  class  the  amount  of  meat  may  not  be 
so  great  or  varied  (though  meat  may  find  an  equivalent  as 
regards  nitrogen  in  cheese).  Almost  invariably  beer  is  the 
beverage ;  very  often  porter  is  drunk  in  addition  to  ale,  or 
instead  of  it.     Heavy  muscular  work  is  not  a  characteristic 


540  THE  TREATMENT  BY  MEAT  DIET 


of  those  of  this  class  who  develop  gout.  Their  case  is 
really  not  far  different  from  that  first  described.  They  are 
relatively  overfed,  deriving  their  saccharine  supplies  with 
considerable  regularity  from  beer,  whilst  they  do  not  give 
up  ordinary  meat. 

A  feature  common  to  both  these  diets  is  the  abundant 
and  regular  supply  of  saccharine,  which  may  often  be 
almost  equivalent  to  the  body-waste,  and  yet  is  but  a 
foundation  for  the  heavy  nitrogenous  contingent  of  food 
and  for  the  hydro-carbons,  which  are  usually  well  borne 
and  well  digested.  Thus  the  food-supply  is  partly  of  a 
very  easily-assimilable  sort  (saccharine),  partly  of  a  high 
potential  (nitrogenous). 

In  dealing  with  these  various  supplies  the  liver  is  fully 
taxed,  often  overtaxed  ;  but  it  is  doubtful  whether,  with- 
out the  animal  food,  the  hepatic  difficulty  would  culminate 
in  gout. 

One  of  the  strongest  proofs  of  the  gout-producing 
tendency  of  a  meat  diet  is  the  prevalence  of  gout  among 
the  Parsees,  who  are  large  meat-eaters.  Their  liability  to 
gout,  in  spite  of  the  protecting  influence  of  the  climate  of 
India,  is  rendered  more  striking  by  the  immunity  enjoyed 
by  the  natives,  and  even  by  those  among  the  English  who 
had  suffered  from  gout  in  England,  so  long  as  they  remain 
careful  in  their  diet. 

Until  these  facts  can  be  explained  away,  we  cannot 
admit  that  butcher's  meat  is  the  proper  food  for  the  gout, 
however  helpful  it  may  prove  for  a  time  for  gouty  dyspepsia 
with  inability  to  digest  other  food. 

VEGETARIANISM. 
Of  the  value  of  vegetarianism  for  the  cure  of  a  variety  of 
symptoms  usually  attributed   to  a  disordered   liver,   but 
perhaps  occasioned  in  susceptible  subjects  by  the  peptic 


VEGETARIANISM  541 


products  of  animal  food,  there  cannot  be  any  doubt.  In 
lithcemia  itself  a  change  to  vegetarianism  from  the  mode  of 
living  which  brought  about  the  unhealthy  state,  when 
carried  out  with  earnestness  and  clinical  tact,  is  a  safe 
remedy,  as  successful  as  it  is  rational.  The  constantly  re- 
curring absorption  of  animal  juices  into  a  blood  already 
overcharged  with  nitrogenous  waste  products  keeps  up  the 
lithaemia.  Vegetarianism  strikes  at  the  root  of  this  evil  by 
supplying  the  needful  nitrogen  without  any  of  the  waste 
products.  The  depression,  the  languor,  the  lassitude  and 
unfitness  for  exertion,  which  are  so  many  symptoms  of 
nerve  intoxication,  quickly  vanish,  and  the  impaired 
powers  of  digestion  are  renewed. 

The  close  relationship  subsisting  between  lithsemia 
and  gout,  and  the  large  share  which  we  have  attributed  to 
the  liver  in  the  aetiology  of  the  latter,  would  lead  us  to 
expect  a  similar  benefit.  To  a  limited  extent  this  expecta- 
tion has  been  realized.  Patients  have  been  known  to 
remain  free  from  gout  so  long  as  they  adhered  to  vege- 
tarianism and  to  abstinence  from  wine,  and  to  relapse  on 
returning  to  an  animal  diet.  Few,  however,  seem  to  have 
made  the  experiment.  It  is  significant  that  the  greatest 
authorities  on  gout,  from  antiquity  onwards,  have  been 
almost  unanimous  in  their  distrust  of  vegetarianism.  Even 
Mead  (1673-1754),  who  believed  that  in  its  earlier  stages 
gout  was  curable  by  a  milk  and  vegetable  diet,  generally 
allowed  a  small  quantity  of  tender  meat  once  a  day. 
Gairdner  thinks  that  a  vegetarian  diet,  when  attempted, 
has  led  to  great  aggravation  of  the  patient's  sufferings. 
Scudamore,  Garrod,  Lecorche,  and  Rendu  have  all  ex- 
pressed their  disapproval  of  the  method.  Some  of  this 
discredit  has  probably  arisen  from  the  unsuitability  of 
cases  in  which  it  had  been  tried.  As  pointed  out  by  Sir 
Dyke  Duckworth,   patients  of  mature  years   are  not  fit 


542  VEGETARIANISM 


subjects  for  so  great  a  change.     Even  the  milk  treatment 
is  best  tolerated  by  relatively  young  stomachs. 

In  addition  to  the  idiosyncrasies  of  the  individual  which 
preclude  any  rigid  uniformity  in  the  dietary,  we  have  to 
deal  in  gout  with  every  stage  and  degree  of  the  disease 
between  the  opposite  extremes  of  gouty  plethora  and  of 
gouty  cachexia.  In  a  large  number  of  cases  debility  is 
the  leading  feature,  and  calls  for  the  stimulation  of  animal 
food.  Even  in  the  remaining  class,  in  which  the  complete 
avoidance  of  animal  food  might  have  the  best  results, 
vegetarianism  is  difficult  to  enforce,  and  irksome  to  prac- 
tise, and  a  mixed  diet,  with  a  moderate  supply  of  meat, 
will  prove  to  be  the  only  one  suited  for  general  application. 


CHAPTER  LXI. 
THE  PRINCIPLES  OF  DIET  IN  GOUT. 

THE  CHEMICAL  PRINCIPLES  OF  DIET. 

We  have  sought  to  define  the  fundamental  principles 
which  must  be  regarded  in  constructing  a  rational  dietary 
of  gout.     They  are  the  following  : 

1.  Nitrogenous  food  of  all  kinds,  whilst  it  largely  increases 
the  output  of  urea,  raises  slightly  the  total  output  of  uric 
acid,  probably  through  increasing  the  total  nitrogenous 
metabolism. 

2.  Animal  food,  taken  iii  excess,  favours  the  production 
of  gout ;  taken  in  moderation,  it  is  not  usually  harmful, 
but  the  reverse,  to  gouty  subjects.  The  detrimental  influence 
of  animal  food  is  not  entirely,  if  ever,  due  to  the  uric  acid 
which  it  contains,  nor  to  the  slightly  increased  production 
of  uric  acid  to  which  it  gives  rise  in  about  the  same  pro- 
portion as  nitrogenous  vegetarian  food.  More  probably  it 
is  due  to  other  factors,  and  perhaps  to  leucomaines. 

3.  Carbo-hydrates  and  fats,  though  incapable  of  trans- 
formation into  uric  acid,  nevertheless  influence  the  meta- 
bolism which  gives  rise  to  it.  Gout  being  largely  deter- 
mined by  disturbance  of  digestion,  and  consisting  essentially 
in  a  faulty  metabolism,  they  cannot  be  regarded  as  free 
from  an  active  share  in  the  production  of  gout,  since  they 
are  largely  responsible  for  the  dyspepsia. 

4.  A    diet  mainly  of  animal  food,  whilst  simplifying  in 


544  THE  GENERAL  DIETETIC  PRINCIPLES 

many  cases  the  work  of  gastric  digestion,  is  productive  of 
other  consequences  which  render  it  unsuitable  in  gout. 

5.  A  vegetarian  diet,  which  generally  supplies  less 
nitrogen  than  an  animal,  or  a  mixed  diet,  does  good  chiefly 
by  simplifying  the  process  of  digestion,  by  alkalizing  the 
blood,  and  by  lessening  the  accumulation  and  stopping 
the  intake  of  the  nitrogenous  waste-products.  These  ad- 
vantages are  probably  of  greater  value  in  gout  than  the 
mere  reduction  in  the  accumulation  of  uric  acid. 

THE  GENERAL  DIETETIC  PRINCIPLES. 

Man  is  omnivorous.  His  entire  system  of  dietetics  is 
based  upon  this  fact.  Whilst  theoretically  the  purest 
blood  is  to  be  secured  from  the  natural,  non-animalized 
foods,  free  from  all  suspicion  of  contamination,  we  cannot 
disregard  the  existence  of  his  carnivorous  instinct  and  the 
practical  advantages  of  an  animal  diet.  Meat  will  there- 
fore form  part  of  his  diet  ;  but  the  amount  to  be  taken 
will  depend  upon  his  pursuits,  his  surroundings,  and,  above 
all,  upon  the  climate. 

This  omnivorous  character,  and  the  singular  adaptability 
which  he  possesses,  in  a  higher  degree  than  any  of  the 
animals,  for  diet  and  for  climate,  also  enable  him  to  sub- 
sist on  exclusive  foods — at  any  rate  for  a  time,  provided 
they  contain  the  indispensable  proportions  of  the  primary 
principles.  In  this  way  he  can  live  on  purely  animal 
diet,  or  become  a  pure  vegetarian.  These  are  provisions 
of  nature  intended  to  meet  special  contingencies,  not  for 
common  application. 

The  Proper  Mixture  of  the  Elementary  Food-stuffs. — Milk  is 
in  this  respect  the  type  of  all  foods,  containing  abundant 
nitrogen  in  its  casein,  and  abundant  fat,  sugar,  and  salts. 

Persistent  deprivation  from  any  of  the  primary  food- 
stuffs inevitably  leads   to  weakness,  or  even  to  disease ; 


THE  GENERAL  DIETETIC  PRINCIPLES  545 


scurvy  is  the  most  striking  instance  in  point.     This  is  not 
one  of  the  causes  or  dangers  of  gout. 

A  mixture  of  the  various  classes  of  food  is  also  an  indica- 
tion of  nature,  and  this  is  a  standing  argument  against 
vegetarianism.  Whenever,  owing  to  some  accidental  or 
constitutional  cause,  or  to  habit,  a  disability  for  certain 
classes  of  food  exists,  we  should  aim  at  restoring,  if  pos- 
sible, that  healthful  variety  in  the  supplies  which  is 
essential  to  the  highest  type  of  nutrition. 

There  is  a  moral  side  to  digestion  which  must  be  thought 
of,  as  well  as  the  chemical, — a  gastric  nervous  system  to 
cheer  and  stimulate,  peptic  functions  to  feed  and  to 
encourage,  an  assimilation  to  influence  through  the  im- 
proved energy  of  the  stomach.  All  these  indications  will 
be  best  fulfilled  by  our  sanctioning  the  judicious  use  of 
aliments  free  from  major  objections,  so  long  as  they  act 
as  aids  to  digestion  and  raise  the  general  tone,  and  with  it 
also  the  general  fitness  for  exercise.  Thus,  the  severity  of 
the  strictest  rules  may  often  be  relaxed  with  greatest 
benefit,  so  long  as  we  can  secure  some  corresponding 
advantage  in  the  direction  of  muscular  or  mental  hygiene. 

A  varied  diet  is  the  indication  for  the  cure  of  diseases  of 
nutrition,  and  eminently  also  for  that  of  gout.  In  gout, 
however,  where  intolerance  often  exists  for  some  special 
foods,  due  regard  must  be  paid  to  the  fact,  though  in 
respect  of  all  remaining  food-stuffs  the  utmost  variety 
should  be  the  aim  to  pursue. 

Complexity  of  meals  is  not  an  indication  of  nature. 
Here,  again,  milk  is  the  type  of  that  simplicity  which 
belongs  to  a  natural  dietary.  The  tolerance  of  a  robust 
stomach  for  a  large  assortment  of  different  foods  at  one 
meal  is  in  itself  a  striking  instance  of  the  omnivorous 
power  of  man,  but  it  is  a  facility  which  cannot  be  per- 
sistently abused  without  serious  detriment.     The  practice 

35 


546  GENERAL  DIETETICS  IN  GOUT 

of  loading  the  most  nutritious  viands  with  rich  sauces  and 
adjuncts  is  an  evil  from  which  escape  is  too  often  difficult 
in  our  modern  conviviality. 

The  selection  of  food  is,  thanks  to  the  unequalled  oppor- 
tunities of  our  civilization,  carried  to  a  high  pitch.  There 
is  some  danger  in  this  perfection.  Whilst  luxuries  should 
be  the  exception,  many  live  exclusively  on  picked  and  dainty 
food,  the  chief  fault  of  which  is  the  ease  with  which  it  is 
absorbed.  The  powers  of  digestion  are  no  longer 
exercised,  as  nature  intends  them  to  be,  by  the  simpler 
and  rougher  food,  the  slow  digestion  of  which  affords 
neither  scope  nor  desire  for  an  undue  frequency  of  meals. 
Again,  with  the  coarser  food,  bulk  is  less  apt  to  mean 
over-saturation  with  nutriment  ;  the  food  is  probably  more 
fully  utilized,  and,  so  long  as  the  stomach  is  equal  to  its 
digestion,  is  less  apt  to  set  up  the  artificial  craving  which 
is  characteristic  of  overfeeding. 

THE  GENERAL  DIETETIC  PRINCIPLES  IN  GOUT. 

In  gout  the  same  principles  apply,  with  certain  reserva- 
tions affecting  chiefly  the  mixture  and  the  variety  of  food. 

The  quantity  of  food  should  be  limited.  Large  eating 
does  not  always  fatten  people,  neither  does  it  always  lead 
to  gout.  Why  those  (as  for  instance  prosperous  butchers) 
habitually  using  an  excess  of  animal  food,  should  some- 
times develop  obesity,  and  sometimes  gout,  is  not  ex- 
plained by  our  theories,  though  we  are  now  aware  that  fat 
may  be  derived  from  nitrogenous  supplies.  Where  gout 
is  established,  moderation  is  essential.  Large  meals  must 
be  avoided. 

For  special  kinds  of  food  a  relative  disability  is  often 
developed  in  gout  and  in  goutiness.  Meat  may  no  longer 
be  tolerated  as  formerly,  and  some  forms  of  it  may,  in 
given  patients,  set  up  marked  disturbance.     More  generally 


GENERAL  DIETETICS  IN  GOUT  547 

the  saccharine  constituents  of  food  are  a  source  of  trouble, 
and  have  to  be  given  up ;  while  in  all  gouty  patients  acids, 
or  any  ingesta  leading  to  acidity,  are  little  short  of 
poison ;  and  even  fresh  fruit  has  been  regarded  as 
distinctly  obnoxious. 

Thus  restricted,  very  little  would  remain  for  the  unfor- 
tunate patient  to  live  upon,  and  he  would  be  sadly  deprived 
of  that  variety  to  which  we  attach  primary  importance  in 
dietetics. 

Often,  however,  the  disability  is  apparent  rather  than  real. 
It  is  the  mixture  and  the  excess  of  food  which  the  gouty 
stomach  can  no  longer  manage.  Except  in  aggravated 
dyspepsia,  any  one  class  of  food-stuffs  taken  separately  will 
be  successfully  digested.  This  is  the  secret  of  the  success 
of  an  exclusive  meat  diet,  of  an  exclusive  milk  diet,  and  of 
pure  vegetarianism. 

Although  none  of  these  exclusive  plans  are  permanently 
practicable,  we  learn  from  them  that  the  essential  principle 
of  diet  in  gout  is  plain  food  and  uncomplicated  mixing  of 
foods.  For  this  reason  the  least  easily-managed  elements  of 
diet — the  carbo-hydrates  and  the  fats — should  not  be  taken 
promiscuously,  and  when  combined  with  others  only  in 
small  quantities  and  in  the  most  simple  form.  This  applies 
particularly  to  the  sugars  and  to  the  fried  fats,  which  will 
inevitably  disagree  if  taken  with  much  other  food. 

The  Value  of  Change  in  Diet. — It  is  sometimes  alleged 
that  any  interference  with  the  habits  of  digestion  and  with 
the  customary  supplies  may  act  detrimentally  in  gout  by 
upsetting  the  function,  and  indirectly  leading  to  gouty 
complications.  In  extreme  old  age  it  is,  doubtless,  wise 
not  to  interfere  with  the  slender  forces  of  digestion, 
which  survive,  as  it  were,  on  the  strength  of  habit ;  and 
anything  suggested  should  be  strictly  in  harmony  with  the 
patient's  instinct  and  experience.      With  gout  at  a  less 


548  GENERAL  DIETETICS  IN  GOUT 

advanced  age,  we  need  not  be  so  timid.  Laziness  of  the 
functions  is  the  fault  to  correct.  Any  rousing  influence, 
whilst  it  may  temporarily  discomfort,  will  ultimately 
benefit  the  patient.  A  similar  result  is  witnessed  at  health 
resorts,  where  passing  attacks  of  gout  are  followed  by 
permanent  improvement.  If  slight  gouty  manifestations 
should  be  brought  about  in  consequence  of  variety  in  the 
diet,  much  will  have  been  gained  if  the  spell  of  habit  has 
been  broken  :  the  stimulating  effect  of  change  is  better 
than  physic. 

There  is  much  that  a  patient  can  do  for  himself  by 
occasionally  varying  the  routine  of  his  accustomed  diet. 
In  this  connection  it  would  be  interesting  to  inquire  into 
the  therapeutic  value  of  fasts,  which  were  probabl}- 
instituted  in  connection  with  some  hygienic  purpose.  It 
is  certainly  remarkable  that  the  time  for  the  Lenten  fast 
should  coincide  with  that  when  the  effects  of  an  unduly 
nitrogenous  diet  are  usually  felt  by  those  predisposed. 

Again,  as  in  diabetes,  we  must  occasionally  relax  the 
restrictions  of  diet.  A  little  cardiac  and  nerve  stimula- 
tion, such  as  may  be  derived  from  the  use  of  tea,  coffee, 
alcohol,  etc.,  which  may  have  been  withheld,  and  the 
cheering  influence  of  variety,  may,  under  ordinary  cir- 
cumstances, do  much  more  good  than  harm.  Neverthe- 
less, there  is  a  danger  not  to  be  lost  sight  of,  lest  habits 
which,  if  continued,  are  detrimental,  should  be  resumed 
as  a  consequence  of  temporary  indulgence. 


CHAPTER  LXII. 

THE  DIETARY  AND  ALCOHOL  IN  GOUT 
AND  GOUTINESS. 

THE  SPECIAL  INDICATIONS  AND  THE  DIETARY  IN 

GOUT. 

The  general  principles  which  have  been  discussed  are  a 
safer  guide  in  the  management  of  individual  cases  than 
any  detailed  formulary.  The  variety  of  gouty  ailments 
and  of  gouty  states  is  such  that  the  attempt  to  suggest 
sets  of  diets  suitable  to  each  requirement  would  be 
futile.  The  diet  must  be  arranged  for  the  individual  case. 
Whilst  the  physician  should  cultivate  freedom  from  rigid 
theory,  the  patient  expects  firm  and  definite  instructions, 
and  will  be  better  able  to  follow  them  if  they  are  written 
or  printed. 

Precise  and  complete  rules,  specifying  the  number,  the 
time,  and  the  composition  of  the  meals,  but  above  all 
what  to  avoid,  are  of  lasting  help  to  the  chronic  gouty 
patient ;  whilst  in  acute  gout  the  diet  has  to  be  recon- 
sidered each  day.  They  are  indispensable  in  the  three 
important  gouty  diseases  in  which  diet  is  the  main  part  of 
treatment. 

DIET  IN  ACID  GOUTY  DYSPEPSIA,  GOUTY  GLYCOSURIA, 
AND  GOUTY  ALBUMINURIA. 

In  all  these  cases  certain  limitations  are  unavoidable, 
but   the   least   severe   measures  will   often  be   the   most 


5 so  DIET  IN  ACID  GOUTY  DYSPEPSIA 

successful.  Our  endeavour  is  to  find  out  what  our  patient 
can  safely  manage,  and  how  his  strength  can  best  be  kept 
up,  rather  than  to  curtail  too  rigidly  the  supplies.  In 
each  case  the  best  dietary  can  only  be  arrived  at  experi- 
mentally, and  by  special  study.  With  this  object,  it  is 
important  that  the  food  should  be  palatable. 

Special  restrictions  are  more  easily  carried  out  in  bed- 
ridden cases  than  in  patients  who  are  going  about.  The 
daily  expenditure  of  the  latter  is  greater,  and  must  be 
compensated ;  they  must  have  sufficient  food,  and  of  a 
kind  which  they  can  digest. 

A  cid  gouty  dyspepsia  in  its  worst  form  is  one  of  the  most 
troublesome  of  ailments.  Its  dietetic  management  does 
not  differ  from  that  of  the  non-gouty  kind.  Milk  may 
be  the  only  aliment  well  borne,  and  may  even  need  to  be 
peptonized.  In  other  cases  lean  meat  or  fish  is  the  chief 
article  of  diet.  Vegetables,  fats,  and  starches  always 
disagree,  unless  taken  in  the  smallest  quantities  and 
thoroughly  prepared.  Some  of  the  infant  foods  may  be 
tried  with  advantage. 

Gouty  albuminuria,  in  its  milder  degrees,  does  not  call 
for  any  special  diet,  but  merely  suggests  constant  watch- 
fulness in  the  avoidance  of  dyspepsia.  Confirmed  organic 
disease  of  the  kidney  is  an  additional  indication  for 
moderation  in  the  use  of  animal  food,  but  seldom  implies 
a  necessity  for  its  suspension.  In  itself,  the  persistent 
drain  of  albumen  rather  points  to  a  need  for  an  adequate 
nitrogenous  supply  ;  but  this  should  be  of  the  least  irritat- 
ing kind.  A  judicious  combination  of  the  more  digestible 
vegetables  and  fruits  with  the  lighter  varieties  of  meat 
and  of  fish,  tends  to  lessen  the  acidity  of  the  urine,  and 
to  increase  the  alkalinity  of  the  blood.  Any  threatenings 
of  uraemia  are  best  treated  by  a  short  course  of  exclusive 
milk  diet. 


THE  DIETARY  OF  GOUT  AND  GOUTINESS  551 

In  gouty  glycosuria  and  diabetes  the  strict  diabetic  diet  is 
not  appropriate.  Neither  its  coarse  and  indigestible  sub- 
stitutes for  wheaten  bread,  nor  its  heavy  suppHes  of  meat, 
are  suitable  for  the  delicate  stomach  of  the  gouty.  If  we 
can  subdue  the  gout,  the  glycosuria  will  lessen,  or  even 
disappear.  Thus,  whilst  the  liverjis  treated  medicinally, 
the  digestion  should  be  humoured.  Well-toasted  bread 
may  be  allowed,  and  sometimes  even  a  moderate  amount 
of  starchy  food.  Sugar  is  best  avoided  ;  but  the  skilful 
use  of  saccharin  will  enable  the  patient  to  enjoy  some  of 
his  favourite  dishes  without  any  harm.  Here,  again,  a 
periodical  resort  to  a  milk  diet  is  much  to  be  recom- 
mended. 

THE  DIETARY  OF  CHRONIC  GOUT  AND  GOUTINESS. 

The  average  gouty  person,  whose  condition  is  not  that 
of  a  confirmed  invalid  under  constant  medical  supervision, 
needs  more  than  any  other  a  clear  notion  of  what  is  allow- 
able and  of  what  should  be  avoided.  The  following  hints 
may  be  of  service. 

Meat  and  fish  may  be  taken  daily,  in  moderation,  but  it 
is  much  the  safer  rule  to  partake  of  them  at  separate 
meals — fish  for  breakfast  or  lunch,  and  meat  for  dinner. 
Neither  salt  meat  nor  salt  fish  is  suitable.  Salmon, 
eels,  mackerel,  and  other  heavy  kinds  of  fish,  are  not 
desirable,  and  should  only  be  indulged  in  occasionally. 
Boiled  fish  is  to  be  preferred  to  fried  ;  and  the  exquisite 
flavour  of  perfectly  fresh  fish  will  be  best  appreciated 
if  sauces  are  wisely  given  up. 

In  the  selection  of  meat,  individual  taste  and  digestive 
power  are  the  chief  guide.  If  the  latter  is  fairly  good, 
variety  will  be  enjoyable  and  of  use.  Butcher's  meat, 
which  Dr.  Mortimer  Granville  advocates  to  the  exclusion 
of  white  meat,  has  the  advantage  of  a  greater  nutritive 


552         THE  DIETARY  OF  GOUT  AND  GOUTINESS 

value,  and  may  be  recommended  to  those  who  adhere  to 
the  rule  of  taking  meat  once  daily,  and  in  moderate 
quantity.  The  objection  to  fowl  and  game  on  the  score 
of  the  slightly  larger  proportion  of  uric  acid  they  contain 
should  not  be  brought  into  line  against  the  great  advantage 
of  variety,  and  against  the  special  value  which  they  pos- 
sess for  those  whose  feeble  digestion  is  not  always  equal 
to  the  stronger  animal  food. 

Vegetables,  if  properly  digested,  can  only  do  good  by 
their  alkalizing  and  depurative  effect  on  the  blood.  The 
avoidance  of  preserved  and  pickled  vegetables,  and  of  all 
coarse  fibrous  parts  in  fresh  vegetables,  is  an  elementary 
rule.  Celery  and  lettuce  have  enjoyed  a  special  reputa- 
tion in  gout.  The  majority  of  the  common  vegetables 
agree.  Potato,  peas  and  beans,  artichoke,  salsify,  onion, 
turnip,  greens,  and  particularly  cabbage,  are  all  allow- 
able. Carrot  and  beetroot,  which  contain  much  sugar, 
must  be  used  sparingly. 

There  is  a  group  of  vegetables  which  cannot  be  recom- 
mended to  the  generality  of  gouty  patients,  although 
individual  tolerance  may  exist  for  some  of  them.  Aspar- 
agus has  long  been  regarded  with  suspicion.  Opinions 
differ  as  to  the  nature  of  the  irritant,  whether  simply 
oxalate  of  calcium,  aspartic  acid,  or  asparagin.  This 
luxury  is  to  be  avoided,  or  used  with  great  moderation. 
Tomatoes,  rhubarb,  and  sorrel  are  exceedingly  acid,  and 
usually  disagree  ;  they  contain  an  abundance  of  oxalate. 

Fruit  is  theoretically  indicated.  Yet,  apart  from  the 
idiosyncrasy  which  sometimes  forbids  the  use  of  an}-,  or 
of  special  kinds  of  fruit,  in  general  all  gouty  subjects  have 
to  exercise  much  discretion  in  this  matter.  Fruit  is 
inadmissible  in  the  later  hours  of  the  day,  and  especially 
after  a  full  meal,  or  in  conjunction  with  wine.  The  safest 
time  is  the  early  morning  before  breakfast,  or  the  middle 


THE  DIETARY  OF  GOUT  AND  GOUTINESS         553 

of  a  long  interval  between  meals.  Whether  taken  before 
or  after  meals,  or  as  an  intrusion  upon  the  valuable  periods 
when  the  stomach  is  at  rest,  fruit  does  not  aid  digestion ; 
it  is  a  complication,  and  we  do  not  wonder  at  patients 
spontaneously  or  under  advice  giving  up  its  use  entirely. 
Exceptions  are  found  to  every  rule,  even  with  regard  to 
fruit.  Thus  strawberries  were  considered  by  Linnaeus* 
to  be  antagonistic  to  gout,  though  generally  found  to  be 
difficult  of  digestion.  Apples  and  pears,  disapproved,  as 
well  as  all  stone  fruit,  by  most  authorities,  have  enjoyed 
a  reputation  for  the  alleviation  of  gout,  which  is  to  some 
extent  supported  by  practical  experience.  Grapes  and 
oranges,  which  easily  yield  their  juice  without  any  of  the 
indigestible  substance  being  swallowed,  are  of  all  fruit 
the  most  suitable. 

Baked  apple  and  various  kinds  of  stewed  fruit  may  be 
taken,  but  not  the  sweet  juice  which  accompanies  the 
latter. 

Of  sweet  dishes  it  need  merely  be  said  that  they  are 
unsuitable  for  the  gouty  in  the  measure  of  their  elaborate- 
ness. To  the  simple  puddings  made  with  rice,  sago, 
tapioca,  and  similar  preparations,  there  can  be  no  objec- 
tion. Pastry  should  be  avoided ;  its  place  might  be  taken 
by  the  harmless  dry  biscuits. 

THE  EXCLUSIVE  DIETS  IN  THE  VISCERAL 
COMPLICATIONS  OF  CHRONIC  GOUT  AND  GOUTINESS. 

When  some  visceral  complication,  hepatic,  renal,  or 
intestinal,  interrupts  the  even  tenour  of  health,  great 
advantage  may  accrue  for  the  gout  as  well  as  for  the 
visceral  complication  from  a  period  of  relative  physio- 
logical rest  for  the  digestion.  This  may  be  secured  by 
combining  with  rest  in  bed  abstinence  from  animal  food, 

*  C/.  Garrod,  loc.  cit,  p.  396. 


554  EXCLUSIVE  DIETS  IN  VISCERAL  COMPLICATIONS 

or,  better  still,  an  exclusive  milk  diet.  In  the  former 
case,  the  full  measure  of  the  ordinary  vegetarian  diet 
might  be  allowed ;  in  the  latter  milk  only,  with  or  with- 
out the  addition  of  bread  and  light  pudding.  Although 
ill  suited  for  gouty  subjects  able  to  lead  a  relatively  active 
life,  these  simpler  foods  suit  the  lessened  needs  of  the 
bedridden  invalid,  and  relieve  the  overtaxed  or  weakened 
functions. 

Sydenham  does  not  allude  to  this  temporary  method, 
but  gives  us  his  experience  of  the  continuous  treatment 
by  milk,  of  which  he  disapproves.*  None  of  the  evil 
which  he  describes,  but  only  good,  can  arise  from  the 
temporary  restriction  under  the  favouring  influence  of 
rest.  A  few  days  will  suffice  to  effect  great  improvement 
in  appropriate  cases.  Passive  exercise  and  massage  may 
sometimes  be  profitably  combined  with  the  milk  cure, 
and  the  depurative  action  of  the  fluid  diet  may  thus  be 
greatly  assisted. 

THE  USE  OF  ALCOHOL  IN  GOUT  AND  GOUTINESS. 

It  cannot  be  gainsaid  that  our  prevailing  attitude  towards 
alcohol  is  a  compromise.  Alcohol  is  bad  for  the  gout,  but 
often  good  for  the  patient.  Sydenham  wrote  :  '  The  old 
saw  is  that  "  If  you  drink  wine  you  have  the  gout,  and  if 
you  do  not  drink  wine  the  gout  will  have  you."  The  first 
part  is  true  enough.  It  is  proved  by  the  experience  of 
patients   that  wine  is    absolutely  hurtful.  .  .  ,      Add   to 

*  '  A  milk  diet  (the  milk  being  either  raw  or  boiled),  with  nothing 
besides  but  a  little  bread,  has  prevailed  for  the  last  twenty  years.  It 
has  done  good  so  long  as  it  has  been  rigidly  attended  to  ;  the  moment, 
however,  that  the  patient  swerves  from  it  a  hair's  breadth,  and  the 
moment  he  betakes  himself  to  the  diet  of  a  healthy  man  (no  matter 
how  mild  and  simple),  the  gout  returns  worse  than  ever.  This  is 
because  the  principles  of  Nature  have  been  weakened,  so  that  the 
disease  becomes  more  obstinate  and  dangerous  in  proportion  as  the 
patient  is  unable  to  resist  it.' 


THE  USE  OF  ALCOHOL  IN  GOUT  AND  GOUTINESS  555 

this  the  effect  of  wine  (habitually  taken)  in  making  the 
body  soft  and  loose  like  that  of  females  ;  whereas  tem- 
perate liquors  so  give  tone  and  strength  to  the  constitu- 
tion that  water-drinkers  scarcely  know  what  gout  is.'  But 
he  adds,  further  on  :  '  This  is  a  rule  for  the  gouty  :  They 
may  take  those  liquors  which  neither  chill  the  stomach 
nor  intoxicate  in  any  moderate  quantity.  Such  is  the 
small  beer  in  our  own  country,  which  in  foreign  countries 
may  be  replaced  by  weak  wine-and-water.  Water  alone 
is  bad  and  dangerous,  as  I  know  from  personal  experience. 
When  taken,  however,  as  the  regular  drink  from  youth 
upwards,  it  is  beneficial.  Those  who  take  a  diet-drink 
instead  of  beer  may  allow  themselves  greater  latitude  in 
the  points  of  regimen.' 

The  principles  laid  down  by  Sydenham  are  almost 
identical  with  those  which  still  guide  our  practice. 

The  Share  of  Alcohol  in  the  Etiology  of  Gout. — Alcoholism 
pure  and  simple  in  its  extreme  form  does  not  generate  gout. 
The  spirit-drinking  inebriate  is  exposed  to  more  serious 
ills,  among  which  gout  is  not  included.  This  is  perhaps 
to  be  explained  by  his  habitually  underfed  condition,  due 
to  the  weakening  of  the  digestive  function  and  of  the 
appetite.  This  marked  immunity  is  the  more  striking 
since,  according  to  Hammond  and  Boecker,*  whilst  urea 
is  considerably  diminished,  uric  acid  either  remains  con- 
stant or  is  slightly  increased  by  alcohol ;  and  since  leuco- 
cytosis,  with  which  a  rise  in  the  output  of  uric  acid  is 
always  associated,  is  among  the  results  of  the  consump- 
tion of  alcohol.  The  same  conclusion  has  been  pointed 
out  in  the  chapter  on  lead  intoxication. 

According  to  Sir  W.  Roberts,  alcoholic  beverages  in 
moderation  exert  no  appreciable  influence  on  the  quantity 
of  uric  acid   produced  in   the    body ;    neither   does    the 

*  Quoted  by  Rendu,  loc.  cit,,  p.  181. 


556  THE  USE  OF  ALCOHOL  IN  GOUT  AND  GOUTINESS 

admixture  of  any  of  them  modify  in  any  way  the  resuhs 
of  the  experiments  conducted  with  various  fluids.  He  con- 
cludes {loc.  cit.,  p.  125)  that  '  the  special  part  played  by 
some  of  them  in  the  genesis  of  the  gouty  constitution, 
and  in  fostering  a  proclivity  to  uratic  depositions,  is 
evidently  of  a  very  subtle  and  complex  character,  and  has 
apparently  no  direct  reference  to  the  chemical  problems 
discussed.' 

Whilst  alcohol  pure  and  simple  does  not  produce  gout, 
the  fermented  alcoholic  beverages  are  known  to  do  so. 
These  facts  point  strongly  to  the  important  part  played  by 
the  acid  products  of  digestion  as  direct  setiological  factors. 
Uric  acid  cannot  be  directly  produced  from  alcohol, 
neither  can  it  be  produced  from  the  constituents  of 
wine  ;  thus  the  different  influence  of  the  two  beverages 
cannot  be  explained  on  the  theory  of  uric  acid  excess. 
Again,  were  gout  merely  dependent  upon  a  retardation 
of  the  metabolism,  alcohol  might  have  sufficed  to  have 
produced  the  affection;  but  we  find  that  it  does  not.  As 
pointed  out  by  Sir  A.  Garrod,  it  is  only  the  imperfectly 
fermented  alcoholic  beverage  which  promotes  gout.  The 
determining  factor  would  thus  appear  to  be  the  inter- 
ference with  healthy  digestion  by  the  acidity  induced  by 
wine  or  beer. 

PRACTICAL  CONCLUSIONS  AS  TO  THE   USE  OF 
ALCOHOLIC  BEVERAGES. 

In  acute  gout  alcohol  in  any  form  is  contra-indicated  ; 
the  need  for  it  may  arise,  but  is  exceptional. 

In  chronic  gout  the  chief  value  of  alcohol  is  dietetic.  To 
a  large  number  of  patients,  who  have  long  been  accus- 
tomed to  stimulants,  it  is  indispensable  as  a  stomachic. 

Whatever  view  may  be  taken  of  the  alcoholic  question 
in  gout,  the  importance  of  securing  a  healthy  digestion 


THE  USE  OF  ALCOHOLIC  BEVERAGES  557 

is  paramount.  Much,  therefore,  depends  upon  the  right 
selection  of  the  stimulant. 

Comparative  safety  lies  in  avoiding  all  wines  and  malt 
liquors,  and  in  trusting  to  that  form  of  spirit  which  most 
closely  approaches  chemically  pure  alcohol.  The  best 
whisky,  well  matured,  is  therefore  to  be  preferred;  it  is 
usually  well  borne,  even  when  the  liver  is  intolerant  of 
brandy.  A  small  quantity,  diluted  with  water  or  with 
some  light  table  water,  may  be  taken  at  lunch  and  dinner. 
Nothing  more  is  needed,  and  many  gouty  patients  adhere 
faithfully  to  this  rule  with  decided  advantage.  The 
monotony  may  be  varied  by  substituting  brandy  or  gin 
for  whisky  ;  individual  taste  will  often  be  the  best  judge. 

The  selection  of  a  suitable  wine,  where  wine  is  indicated 
or  desired  in  preference  to  spirits,  is  sometimes  facilitated 
by  the  patient's  own  experience.  Idiosyncrasy  is  apt  to 
be  as  marked  in  respect  to  wine  as  in  respect  to  articles 
of  diet,  and  should  be  taken  into  account. 

The  qualities  we  should  look  for  in  a  wine  for  habitual 
use  are  :  a  moderate  percentage  of  alcohol*  and  of  ethers  ; 
the  least  possible  degree  of  acidity ;  freedom  from  unfer- 
mented  sugar  as  far  as  this  is  consistent  with  a  natural 
unadulterated  condition ;  freedom  from  tannin ;  genuine- 
ness as  to  vintage,  or,  at  least,  as  to  derivation,  mixed 
wines  being  most  likely  to  do  harm ;  and,  lastly,  mature 
age.f  The  difficulty  in  securing  these  essentials  is  per- 
haps greater  now  than  at  any  previous  period,  and  adds 
to  the  strength  of  the  general  objection  to  wines  in  gout. 

*  According  to  Duckworth  {loc.  cii.,  p.  426),  the  average  percentage 
of  alcohol  in  spirits  varies  from  35  to  44  ;  port  wine  has  19  per  cent., 
madeira  18  per  cent.,  sherry  17  per  cent.,  champagne  11  per  cent., 
burgundy  10  per  cent.,  bordeaux  and  Rhine  wine  8  per  cent.,  porter 
6  per  cent.,  ale  3  to  6  per  cent.,  and  cider  4  per  cent. 

t  Dr.  Burney  Yeo  lays  stress  upon  the  fact  which  he  has  observed, 
that  those  wines  agree  best  which  act  upon  the  patient  as  diuretics. 


5S8  THE  USE  OF  ALCOHOLIC  BEVERAGES 

The  gouty  wines,  which  most  depart  from  this  standard, 
and  which  are  found  to  disagree,  are  above  all  the  sweet 
and  heady  wines  of  the  South,  which  are  not  much  used 
in  this  country ;  and  among  those  in  common  use,  port, 
sherry,  madeira,  and  burgundy.  Sydenham,  who  allowed 
a  little  wine  at  meal-times  '  as  a  medicine  rather  than  as 
a  drink,'  regarded  sherry  as  preferable  either  to  Rhenish 
or  French  wines,  but  he  most  approved  of  Canary  :  '  I 
have,  during  the  fits  of  the  last  years,  tried  many  things 
to  lessen  the  symptoms.  Nothing,  however,  effected  my 
purpose  so  much  as  a  small  draught  of  Canary  wine,  taken 
now  and  then,  when  the  faintness  and  sickness  were  most 
oppressive.'  Neither  the  sherry  nor  the  Canary  wine  of  the 
present  day  has  earned  the  approval  of  those  who  have 
tried  them,  though  Canary  is  less  gouty  than  madeira. 

Claret  of  the  best  kind,  and  in  good  condition,  is  much 
less  gouty  than  burgundy,  and  is  decidedly  the  most 
useful  wine  for  the  generality  of  patients.  Dry  moselle  is 
regarded  by  Sir  Dyce  Duckworth  as  preferable  to  Rhine 
wines,  which  are  said  to  be  detrimental. 

Champagne  is  apt  to  be  the  worst  of  all  wines  in  gout, 
but  it  has  found  in  Dr.  Mortimer  Granville  a  strenuous 
supporter.  Its  effect  on  the  gouty  subject  is  largely  a 
question  of  quality.  Some  of  the  inferior  kinds  combine 
almost  every  harmful  peculiarity.  Even  the  best  are 
not  entirely  free  from  the  disadvantages  arising  from  an 
artificial  process  of  manufacture.  It  is  wiser  for  the  gouty 
patient  not  to  incur  considerable  risks  by  trying  brands 
with  which  he  is  not  familiar,  though  he  may  sometimes 
with  impunity,  and  occasionally  with  benefit,  enjoy  a 
glass  of  a  champagne  which  he  can  trust  from  personal 
experience. 

With  all  wines  quantity  has  a  great  share  in  deter- 
mining the  result.     Even  port  wine  is  often  tolerated  if 


THE  USE  OF  ALCOHOLIC  BEVERAGES  559 

the  amount  taken  be  sufficiently  small.  Many  a  patient 
finds  himself  the  better  for  a  glass  or  two  of  old  port 
daily,  and  when  this  practice  is  not  productive  of  appre- 
ciable harm,  we  need  not  interfere  with  its  continuance. 
It  is  not,  however,  one  which  we  could  recommend  for 
general  adoption. 

Ale  and  stout  are  strictly  to  be  avoided.  On  this  point 
the  patients  and  the  physician  are  in  complete  agreement. 
Ebstein*  forbids  the  use  of  beer  on  account  of  the  carbo- 
hydrates which  it  contains,  but  thinks  that  wine  need 
not  be  excluded  if  of  the  right  kind,  and  taken  in  small 
quantities. 

Cider  is  not  open  to  the  same  objections  as  beer.  In  the 
districts  in  which  it  is  largely  consumed  gout  is  not 
markedly  prevalent.  A  distinction  has,  however,  to  be 
made  between  the  sweet  or  imperfectly  fermented  and  the 
rough  cider.  According  to  Sir  Dyce  Duckworth,  who 
quotes  Mr.  Richard  Davy's  observations,  the  former  is 
capable  of  provoking  gout ;  the  latter  does  not  do  so 
unless  combined  with  gin,  alcohol,  or  beer. 

The  notion  that  cider  may  dispel  the  gout  is  probably 
based  upon  the  immunity  enjoyed  by  those  who  make  it 
their  exclusive  beverage.  As  pointed  out  by  Duckworth, 
other  factors  co-operate  with  any  influence  it  may  possess  : 
an  open-air  and  laborious  life,  associated  with  free 
cutaneous  action,  such  as  that  of  Devonshire  labourers, 
would  probably  be  successful  in  curing  many  cases  of 
goutiness.  The  consumption  of  cider  at  home  without 
this  saving  clause  would  end  in  failure,  if  it  did  not  at 
once  lead  to  gastric  or  intestinal  complications. 

*  Ebstein  (/<?<:.  «'/.,  p.  167)  quotes  Mooren's  observation  that  the 
acids  of  urine  were  least  increased  on  Dortmund  beer,  much  more 
increased  by  Rhine  wine,  more  still  by  the  choice  kinds  of  moselle  and 
old  bordeaux,  and  most  of  all  by  the  ordinary  moselle. 


CHAPTER  LXIIL 

HYGIENE  AND  PROPHYLAXIS  IN   GOUTINESS 
AND  IN  GOUT. 

HYGIENE  IN  CONNECTION  WITH  THE  TREATMENT 
OF  GOUT. 

This  is  the  age  of  hygiene.  Much  has  been  done  for  the 
prevention  or  cure  of  various  diseases  by  attention  to 
hygienic  principles.  Gout  claims  a  large  share  of  the 
same  method ;  and  its  treatment,  apart  from  the  acute 
attacks,  is  mainly  an  adaptation  of  the  laws  of  health  to 
the  peculiarities  of  the  constitutional  affection. 

The  section  of  hygiene  specially  concerned  is  not  sani- 
tation in  the  ordinary  sense,  which  seeks  to  protect  us 
from  effluvia,  from  putrescible  accumulations,  and  other 
dangers,  but  the  internal  sanitation  which  should  regulate 
our  supplies  and  dispose  of  our  waste  products.  This 
object  of  treatment  is  in  harmony  with  the  pathological 
view  which  identifies  gout  with  the  faulty  nutrition  of  an 
originally  healthy  organism. 

The  chief  aspects  of  hygiene  in  gout  relate  to  the  influence 
of  open  air  and  of  climate,  of  temperature  and  of  the 
action  of  the  skin,  of  muscular  exercise,  of  mental  activity, 
and  of  rest  and  sleep.  The  principle  which  should  guide 
our  management  of  diet,  that  of  combining  the  greatest 
support  to  the  system  with  the  least  fatigue  to  the 
functions,  applies  equally  to  this  no  less  important  branch 
of  treatment. 


PROPHYLAXIS  561 


PROPHYLAXIS. 

Prophylaxis,  in  the  wider  sense,  is  identical  with  perfect 
hygiene ;  its  object  is  the  prevention  of  gout  in  those 
strongly  predisposed  by  heredity,  and  in  others  whom  age, 
previous  habits,  and  existing  circumstances  of  life,  expose 
to  an  obvious  risk  of  acquiring  the  affection.  The  larger 
and  most  useful  function  of  hygiene  is  the  protection  of 
the  younger  lives  and  of  those  of  middle  age  who  have 
not  yet  fallen  victims  to  declared  gout.  The  other  func- 
tion is  corrective  and  palliative ;  its  operations  are,  more 
or  less,  restricted  by  the  general  delicacy  which  they  seek 
to  remedy,  or  by  the  local  changes  induced  by  the  chronic 
affection. 

In  the  following  remarks  we  shall  not  endeavour  to 
sketch  out  with  completeness  the  method  of  prophylaxis 
applicable  in  early  life.*  Its  principles  do  not  widely 
differ  from  those  suitable  in  general  delicacy,  unconnected 
with  any  gouty  proclivity,  and  its  special  details  may  be 
inferred  from  those  to  be  mentioned  in  dealing  with  the 
hygiene  of  gout  and  of  goutiness. 

The  preventive  treatment  of  the  gouty  attacks  is  a  much 
more  limited  subject.  Hygiene  has  a  share  in  it ;  but  its 
greater  part  is  dietetic  and  medicinal.  Prompt  attention 
to  any  ominous  indigestion  or  fit  of  dyspepsia,  or  to 
biliousness  and  constipation,  is  the  essential  therapeutical 
indication. 

THE  OPEN-AIR  CURE:  OXYGEN,  SUNLIGHT,  AND 
RESPIRATORY  THERAPEUTICS. 

One  of  the  chief  objects  in  the  selection  of  a  climate 
for  the  gouty  is  to  enable  them  to  enjoy  perpetually  pure 

*  The  subject  is  referred  to  in  an  interesting  work  by  Dr.  Henry  Cazalis, 
of  Aix-les-Bains, '  Contribution  k  la  Pathogenic  de  I'Arthritisme,'  Paris, 
1895,  which  contains  a  chapter  on  arthritism  in  childhood,  and  its 
prophylaxis. 

36 


S62  RESPIRATORY  THERAPEUTICS 

Open  air — in  the  daytime  out  of  doors,  at  night  with 
widely  open  windows.  Fresh  air  does  good  in  proportion 
as  patients  can  move  about  in  it ;  and  those  merely 
threatened,  or  suffering  from  simple  goutiness,  will  show 
the  greatest  improvement.  The  open-air  method  cannot 
cure  stiff  or  distorted  joints,  but  the  solid  though  latent 
constitutional  gain  is  to  be  valued  the  more  where  a 
relatively  crippled  state  limits  other  treatment,  and  favours 
a  progressive  degeneracy. 

Pure  and  bracing  air  is  a  remedy  adapted  to  every  stage 
and  variety  of  gout ;  but  it  is  of  vital  importance  where  there 
is  a  cachexia  to  check  or  to  ward  off.  In  cachectic  patients 
detained  indoors  by  unavoidable  circumstances,  syste- 
matic oxygen  inhalations  have  been  employed,  and  are  of 
use,  but  they  cannot  compare  with  the  natural  supply  of 
ozone  and  all  its  subtle  influences. 

Mechanical  respiratory  therapeutics  have  been  too  much 
neglected  in  this  country  as  an  essential  part  of  the 
hygienic  treatment  of  nutritional  disorders.  Some  atten- 
tion has  been  devoted  to  them  in  Sweden,  and  more 
recently  in  Germany.  The  cultivation  of  abdominal 
breathing  has  also  been  largely  taken  up  by  professional 
singers  all  over  the  world.  Most  forms  of  athletic  pur- 
suits doubtless  fulfil,  to  a  certain  extent,  the  respiratory 
indication  ;*  but  it  is  in  those  helpless  conditions  where, 
the  mobility  of  the  joints  being  impaired,  active  exercise 
is  precluded,  that  full  oxygenation  is  the  most  needed  and 

*  Dr.  Edward  Blake  insists  that  athleticism  does  not  in  itself  improve 
the  breathing  powers.  He  considers  that  some  athletes  are  amongst 
the  worst  breathers  ;  that  proper  respiration  is  an  art  in  itself,  and  that 
it  requires  special  training,  without  which  athleticism  may  be  most 
injurious.  He  urges  that,  by  using  the  method  he  has  devised,  the 
athlete  secures  a  considerable  respiratory  advantage  with  greatly 
increased  muscular  power.  Cf.  '  Constipation  and  Corpulency,'  p.  13. 
Bale  and  Sons,  1893. 


RESPIRATORY  THERAPEUTICS  563 

the  least  secured.  Much,  indeed,  might  be  done  by  the 
patient  himself,  in  spite  of  considerable  limitation  in  the 
use  of  his  limbs,  by  practising  respiratory  gymnastics, 
carefully  selected  with  a  view  to  his  particular  need. 

Dr.  Edward  Blake,  whose  valuable  contributions  to  the 
study  of  autotoxis  are  so  well  known,  recommends  a 
method*  which  might  be  variously  modified  so  as  to  be 
available  in  most  instances.  The  practical  advantages  of  his 
plan,  as  compared  with  mere  routine  massage,  are  obvious. 
In  addition  to  an  increased  gaseous  interchange,  the  active 
respiratory  method  supplies  important  requirements  in  the 
treatment  of  chronic  gout :  muscular  exercise,  mechanical 
stimulation,  and  movement  of  the  abdominal  viscera, 
more  especially  of  the  liver,  of  the  portal  system  generally, 
and  of  the  other  abdominal  veins.  Much  more  oxygen  is 
introduced  into  the  blood,  and  the  cardio-vascular  system 
and  the  lymphatic  circulation  are  favourably  influenced 
to  a  degree  scarcely  to  be  equalled  by  any  other  method 
in  the  absence  of  active  physical  exercise. 

It  is  probable  that  by  these  means  a  stimulation  of  the 
blood-corpuscle  formation  occurs,  similar  to  that  which 
has  been  recorded  by  so  many  independent  observers,  as 
following  a  change  from  a  low-lying  district  to  a  lofty 
altitude. 

Sunlight  must  now  be  recognised  as  an  essential  part 
of  the  climatic  treatment.  Sunlight  and  sunheat,  as 
we  previously  felt,  but  are  only  now  able  to  conceive, 
thanks  to  Rontgen's  discovery,  may  strike  through  to  the 
bone,  and  may  perhaps  visit  the  seat  of  gout  in  the  joints. 
The  sunlight  cure  has  long  been  practised  at  Veldis  with 
striking  results,  in  connection  with  various  disorders  and 
debilities  ;  but  this  object-lesson  has  been  too  little  heeded 
in  our  hospitals,  few  of  which  possess   the    all-essential 

*  '  Lip  Chorea,'  p.  15  .?/  seg.     Bale  and  Sons,  1890. 


564  CLIMATE 

sun-gallery.  The  influence  of  sunlight  on  health  has 
been  studied  by  various  observers ;  among  others,  by 
Dr.  R.  H.  Clarke  and  Dr.  A.  B.  Blacker,*  by  Dr. 
Samuel  Rideal,  F.C.S.,  and  by  Dr.  Bowles. 

The  Veldis  method  comprises,  besides  the  sun-bath  and 
the  open-air  treatment,  much  in  connection  with  diet 
and  exercise,  which  would  be  of  use  to  selected  cases  of 
goutiness.  Short  of  the  heroic  practice  of  submitting  an 
extensive  cutaneous  surface  to  the  direct  rays  of  the  sun, 
much  may  be  gained  by  a  systematic  enjoyment  of  the 
opportunities  afforded  in  this  country  during  summer, 
and  all  the  year  round  in  more  sunny  climates.  This 
is  one  of  the  chief  recommendations  of  the  altitudes 
during  the  winter  months.  The  intense  radiation  of 
sunlight  and  heat  would  be  invaluable  in  many  cases 
besides  phthisis,  and  amongst  others  in  gout. 

CLIMATE. 

Little  need  be  added  to  the  remarks  made  under  the 
heading  of  mineral  springs.  There  are  two  climatic 
indications  for  the  treatment  of  gout  and  of  goutiness — 
warmth  and  a  bracing  air.  In  a  few  cases  the  condition  of 
the  digestion,  of  the  mucous  membranes,  of  the  liver  or  of 
the  kidneys,  may  need  temporarily  a  soothing  rather  than 
a  tonic  influence.  For  the  greater  number  a  perpetual 
summer  is  the  ideal  climatic  treatment,  to  which  many 
attain  by  spending  the  winter  at  some  distance  from  Eng- 
land. Others  are  content  with  the  relative  warmth  of  the 
South  Coast ;  but  in  selecting  between  its  resorts  warmth 
will  have  to  be  considered  rather  than  mere  bracing 
quality.  Brighton,  which  is  largely  patronized,  combines 
both  virtues.     Abroad  the  winter  colonies  are  also  chiefly 

*  Cf.  Practitioner,  vol.  xlviii.,  'Light  as  a  Therapeutic  Agent.' 


CLIMATE  565 

to  be  found  at  seaside  stations.  Yet,  although  sea-air  is 
preferred  by  some,  it  may  be  doubted  whether  in  many 
cases  a  dry  inland  situation  at  a  good  altitude  would  not 
be  more  beneficial.  In  summer  the  Swiss  Alps  are  largely 
resorted  to  with  great  benefit,  and  a  visit  to  Switzerland 
is  wisely  recommended  at  many  foreign  balnear  stations  as 
a  necessary  complement  of  the  cure.  In  winter  the  Alpine 
resorts  are  not  suitable  for  chronic  arthritic  gout  with 
fixation  of  joints.  There  are,  however,  cases  of  goutiness, 
of  visceral  gout,  and  even  of  gouty  neuralgia,  which  would 
derive  considerable  benefit  from  a  short  winter  season  at 
St.  Moritz  during  the  months  of  January,  February,  and 
March.  Age  and  inability  for  active  exercise  are  absolute 
contra-indications.  But  among  the  younger  and  relatively 
active  subjects  there  are  many  to  whom  the  exhilarating 
effect  of  the  dry  and  pure  air,  of  the  brightness  of  sky  and 
of  the  intensity  of  solar  radiation,  and  the  invigorating 
effect  of  the  long-continued  frost,  would  prove  of  greater 
value  than  the  merely  protective  virtues  of  the  Mediter- 
ranean resorts. 

Increased  capacity  for  exercise  is  among  the  special 
recommendations  of  the  Alpine  treatment ;  and  the 
respiratory  indication  to  which  we  have  referred  is  ful- 
filled unconsciously,  owing  to  the  great  demands  made 
b)^  the  rarefied  air  upon  the  respiratory  muscles. 

Although  perspiration  is  not  usually  noticeable,  the 
dryness  of  the  air  promotes  insensible  exhalation  from 
the  skin,  and  the  cutaneous  indication  is  not  altogether 
neglected. 

In  spite  of  its  many  advantages,  this  tonic  treatment 
is  only  suited  to  a  limited  number  of  subjects,  and  calls 
for  judicious  selection  of  cases. 

Patients  ready  to  submit  to  the  more  radical  measure 
of  a  long  residence  in  the  altitudes,  to  an  active  open-air 


566  THE  SKIN  AND  PERSPIRATION 

life,  and  to  a  diet  chiefly  of  milk  and  of  the  vegetarian 
kind,  are  too  exceptional  to  justify  further  reference  to 
this  treatment. 

Among  the  winter  resorts  available  and  to  be  recom- 
mended for  those  able  to  travel  should  be  mentioned 
Madeira  and  the  Canary  Islands.  A  trip  to  India  or  to 
the  West  Indies,  to  Australia  or  New  Zealand,  or  to  the 
South  Californian  resorts,  will  appeal  only  to  the  few. 

THE  SKIN  AND  PERSPIRATION. 

The  hygiene  of  the  skin,  an  essential  part  of  the  treatment 
of  gout,  has  a  twofold  object :  to  strengthen  the  integu- 
ment, and  through  it  the  nervous  system  and  the  entire 
economy,  and  to  stimulate  the  excretory  function  and 
promote  free  cutaneous  action.  Cold  or  tepid  affusions, 
sea-water  baths  or  salt  baths,  friction,  and  massage, 
afford  us  a  choice  of  tonic  remedies,  which  will  have  to 
be  varied  according  to  individual  requirements.  These 
methods  were  practised  by  the  ancients,  and  combined 
with  the  use  of  the  hot  bath  and  of  the  vapour  bath. 
The  latter  are  still  our  most  valuable  aids  in  promoting 
cutaneous  excretion,  which  is  the  second  indication.  The 
Turkish  bath  is  often  resorted  to  with  advantage.  It 
does  not,  however,  possess  absolute  control  over  the 
gouty  conditions.  Sir  A.  Garrod  states*  that  he  has 
known  patients  experience  severe  attacks  of  gout,  although 
taking  a  Turkish  bath  almost  every  day.  This  fact  is 
significant,  and  reminds  us  of  the  possible  results  which 
may,  according  to  Sir  W.  Roberts,  attend  a  sudden 
dehydration  of  the  tissues  and  of  the  joints. 

The  immunity  from  gout  peculiar  to  hot  climates  has 
been    ascribed    to   the    free   action   of  the  skin  kept    up 

*  Loc.  a'/.,  p.  402. 


THE  SKIN  AND  PERSPIRATION  567 

continuously.  Nevertheless,  the  protection  afforded  by- 
perspiration  is  not  sufficient  to  counteract  the  effect  of 
habitual  indulgence  in  animal  food :  this  is  well  shown  in 
the  case  of  the  Parsees  in  India. 

The  best  form  of  perspiration  for  the  relief  of  a  gouty 
tendency  is  that  arising  from  muscular  exercise.  Dr. 
Haig*  observes  that  the  labouring  man  has  summer  with 
him  all  the  year  round,  and  gets  rid  of  a  large  quantity 
of  acid  by  perspiration  in  winter  as  well  as  during  the 
warm  weather.  During  the  winter  the  sedentary  man  is 
more  acid,  because  less  relieved  through  the  skin. 

*  Loc.  cit.,  p.  321. 


CHAPTER  LXIV. 

MUSCULAR  EXERCISE.— MENTAL  WORK.— 
REST  AND  SLEEP. 

MUSCULAR  EXERCISE  AS  A  PROPHYLACTIC  AND  AS 
A   CURE. 

The  value  of  muscular  exertion  for  the  prevention  and 
for  the  relief  of  gout  was  recognised  by  some  of  the 
earliest  physicians  known  to  history.  Sydenham  ascribes 
to  its  neglect  a  large  share  in  the  production  of  the 
affection  :  '  Add  to  this  the  intermission  or  sudden  aban- 
donment of  those  exercises  to  which  from  their  youth 
upwards  they  have  been  accustomed.  Whilst  these  were 
kept  up  the  blood  was  invigorated,  and  the  tone  of  the 
body  rendered  firm  and  steady.  When,  however,  they 
were  dropped,  the  animal  spirits  gave  way,  the  frame  lost 
tone,  and  the  assimilation  became  imperfect.  Hence  the 
recrementitious  portion  of  the  juices  of  the  body,  which 
had  hitherto  been  cleared  off  by  the  exercise  in  question, 
accumulated  in  the  vessels  and  supplied  the  germ  of  the 
disease.' 

His  statements  as  to  the  curative  value  of  exercise,  even 
in  tophaceous  gout,  are  no  less  explicit  :  '  This  is  con- 
verted into  a  substance  of  the  kind  in  question  in  the  heat 
and  pain  of  the  joint ;  and  it  increases  day  by  day,  con- 
verting into  its  own  proper  substance  both  the  skin  and 
flesh.  The  deposit  now  lies  bare,  and  it  may  be  picked 
out.     It  has  been   compared  to  crab's  eyes,  chalk,  and 


MUSCULAR  EXERCISE  AS  A  PROPHYLACTIC       569 

other  similar  matters.  Now,  this  may  be  guarded  against 
by  daily  exercise,  whereby  we  obtain  the  due  diffusion 
over  the  whole  body  of  the  humours  that  generate  gout, 
instead  of  their  accumulation  in  any  particular  part  of  it 
by  preference.  I  have  found  in  my  own  person  that  long 
and  daily  exercise  not  only  stops  the  generation  of  chalk- 
stones,  but  even  dissolves  old  and  hard  ones  already  formed, 
provided  only  that  they  have  not  gone  so  far  as  to  have  con- 
verted the  outer  skin  into  their  own  proper  substance.' 

The  importance  attached  to  physical  exercise  by  Syden- 
ham could  be  illustrated  by  several  other  quotations  ;  it 
is  the  more  striking  in  contrast  with  his  scepticism  as  to 
the  use  of  physic.  His  ideas  of  the  mechanism  of  the 
relief  afforded  are  in  complete  harmony  with  modern 
speculations.  If  we  are  right  in  regarding  gout  as  a 
perversion  of  the  general  metabolism  of  the  body,  the 
preponderance  in  weight  of  the  muscular  system  over  all 
other  tissues  would  suggest  that  this  m.ust  be  the  chief 
seat  of  the  defect. 

Dr.  H.  Cazalis,*  who  regards  '  arthritism  '  (an  expression 
under  which  gout  is  also  to  be  understood)  as  originally 
dependent  upon  an  inherent  weakness  of  the  connective 
tissues,  quotes  some  important  views  of  Professor  J. 
Renaut,  attributing  the  excess  in  production  of  uric  acid 
and  of  similar  substances  in  gout  to  increased  destructive 
changes  in  the  connective  tissues.  This  increased  cata- 
bolism  is,  according  to  Professor  Renaut,  the  result  of 
an  engorgement  of  the  areolar  system  with  waste  products 
and  with  leucocytes  loaded  with  uric  acid  and  other  effete 
materials.  The  engorgement  is  itself  due  to  a  failure  of 
the  muscles  to  keep  up  an  efficient  lymphatic  circulation  .-f* 

*  C/.  loc.  cit.,  p.  27  et  seq. 

t  Renaut  quotes  Etienne  Rollet's  observation,  that  the  relatively 
inactive  gorilla  is  subject  to  chronic  rheumatism,  which  does  not  affect 
the  smaller  and  nimble  species  of  monkeys. 


570       MUSCULAR  EXERCISE  AS  A  PROPHYLACTIC 

The  primary  fault  lies  with  the  tendency  of  civilization 
to  divert  into  nervous  channels  a  great  part  of  the  energy 
intended  by  nature  for  muscular  work. 

Allowance  being  made  for  the  facts  and  phraseology 
of  modern  science,  we  recognise  in  this  latest  utterance 
on  gout  the  ideas  of  Sydenham.  Muscular  exercise  is  the 
means  of  preventing  lymphstasis  and  all  its  consequences ; 
and  muscular  inactivity  leads  to  encumbrance  of  the 
lymphatics,  and  of  the  loose  connective  tissues,  which 
latter  Cazalis  and  Renaut  regard  as  the  great  internal 
media  of  metabolic  processes. 

Upon  the  reaction  of  the  blood  muscular  work  is  stated 
by  Dr.  Robert  Hutchison*  to  take  a  marked  effect;  it 
reduces  the  alkalinity  of  the  plasma.  Hutchison  refers 
to  the  searching  investigations  of  Cohnstein,-|-  which  place 
this  result  beyond  doubt.  The  change  was  especially 
marked  and  lasting  in  the  case  of  herbivora.  Geppert  and 
Zuntzf  found  in  rabbits  a  reduction  in  alkalinity  in  the 
proportion  of  146  to  248.  Peiper,§  with  the  help  of  the 
titration  method,  was  able  to  trace  in  man  a  reduction  in 
the  proportion  of  182  to  218.  Hutchison  regards  lactic 
acid  as  the  agent,  because,  as  experimentally  proved  by 
Spirojl  and  by  Werther,^  this  acid  is  always  increased  in 
the  blood  after  muscular  exercise.  Sweat,  not  being 
normally  acid,  is  not,  in  Dr.  Hutchison's  opinion,  the 
channel  through  which  acid  is  eliminated  from  the  blood : 

'  The  immediate  fall  in  the  excretion  of  urea  '  (which  Dr. 
Haig  has  shown  to  follow  exercise),  '  is  to  be  explained, 
in    part    at   least,    by   the    elimination    of    some    of    the 

*  Cf.  Lancet,  April  25,  1896,  vol.  i ,  p.  1166. 
t  Cf.  Virchow's  '  Archiv.,'  Bd.  cxxx.,  p.  332,  1892. 
X  Cf.  Pfliiger's  'Archiv.,'  Bd.  xlii.,  p.  233,  1889. 
§  Cf.  Virchow's  '  Archiv.,'  Bd.  cxvi.,  p.  2,37,  1889. 
II   Cf.  Zeitschrift  fiir  Physiol.  CheTfiie,  Bd.  i.,  1878. 
IT  Cf.  Pfliiger's  'Archiv.,'  Bd.  xlvi.,  p.  63,  1890. 


MUSCULAR  EXERCISE  AS  A  PROPHYLACTIC       571 


nitrogen  which  should  appear  as  urea,  in  the  form  of 
compounds  of  ammonia,  these  ammonia  compounds  being 
required  to  neutrahze  the  acids  produced  by  the  excessive 
muscular  metabolism.' 

Dr.  Haig's  latest  views*  are  at  variance  with  those  just 
quoted.  He  draws  attention  to  the  conflicting  statements 
of  authorities  as  to  the  reaction  of  sweat.  Heussf  says 
that  sweat  is  acid  at  the  time  of  its  discharge  from  the 
ducts. 

A  fall  in  the  acidity  of  urine  always,  according  to  Haig, 
accompanies  marked  perspiration,  whether  this  be  pro- 
cured by  the  Turkish  bath  or  by  muscular  exertion  ;  and 
conversely,  as  pointed  out  by  Garrod,  suppression  of 
perspiration  causes  a  rise  in  the  acidity. 

The  fall  of  urea  which  exercise  may  produce,  and  the 
associated  fatigue,  can  both  be  prevented  by  controlling 
the  uric  acid.|  Though,  as  shown  by  Auerbach,§  carnivora 
possess  the  power  of  forming  ammonia  to  neutralize  acids, 
that  power  is  ill  developed  in  man  and  the  frugivora,  and 
this  is  regarded  by  Haig  as  probably  accounting  for  the 
very  different  reactions  of  their  urines,  and  as  support- 
ing the  argument  that  man  is  not  by  nature  a  carnivore. 

Whatever  view  be  taken  of  the  chemistry  of  muscle  and 
of  sweat,  the  broad  practical  conclusions  are  obvious. 

Gout  is  usually  acquired  at  an  age  when  the  vital  pro- 
cesses are  slackening  speed,  the  body-weight  is  increasing 
by  the  deposition  of  fat,  and,  owing  to  many  occupations,  or 
sometimes  to  indolence,  muscular  exercise  has  been  more 
and  more  sacrificed.  Gout  eventually  results  ;  but  it  has 
often  been  long  preceded  by  a  falling  off  in  hygiene.     In 

*  Cf.  Lancet,  May  2,  1896,  p.  1250. 
t  Monatsch.  fiir  Prakt.  Dermat.,  No.  9,  1892. 
\  Cf.  Haig,  Lancet,  March  7,  1896,  p.  614. 
§  Virchow's  '  Archiv.,'  vol.  xcviii.,  p.  512. 


572       MUSCULAR  EXERCISE  AS  A  PROPHYLACTIC 

this  country  a  neglect  of  the  muscular  function  in  middle- 
age  is  probably  resented  in  proportion  to  the  prevalent 
muscular  activity  of  earlier  life. 

Our  lives  are  often  ill  managed  in  this  respect.  Up  to 
the  age  of  thirty  our  muscles  are  always  ready  for  almost  any 
call,  however  long  the  intervals  of  rest.  Between  thirty  and 
forty  this  readiness  is  rapidly  lessening  ;  but  too  often  the 
gradual  change  is  overlooked  till  it  is  almost  past  recovery. 
At  this  stage  distinctions  are  established  between  men  by 
temperament,  by  build,  and  by  occupation.  The  lean, 
active,  and  hard-worked  toilers  suffer  least ;  but  the 
fat,  prosperous,  and  indolent  can  no  longer  keep  pace 
with  them. 

If  the  inevitable  results  could  be  foreseen  in  time,  whilst 
all  works  smoothly  still  and  without  effort,  nothing  would 
be  easier  than  to  maintain  physical  activity  by  regular 
exercise.  Past  a  certain  age,  the  strenuous  effort  to 
recover  lost  ground  is  in  itself  a  risk. 

Most  men  ignore  the  fact  that  with  growing  age 
muscular  efficiency  is  more  and  more  a  matter  of  con- 
stant study.  It  can  only  be  kept  up  by  unceasing  practice. 
Left  to  themselves,  the  organic  activities  follow  their 
downward  course.  Each  day  marks  a  relative  loss  of 
fitness,  unless  the  renovating  influence  be  daily  applied. 

It  is  not  only  the  muscles,  their  nutrition,  suppleness, 
and  power,  which  are  in  question.  The  mainspring  lies  in 
the  heart  and  in  the  pulmonary  function,  without  which 
muscular  activity  is  impossible.  The  right  side  of  the 
heart  and  the  lungs  have  to  be  kept  in  training,  as  the 
indispensable  auxiliaries  to  the  muscular  system,  by 
systematic  regularity  in  exercise. 

The  prevailing  custom  of  taking  full  exercise  once  a 
week,  leaving  the  other  days  unprovided  for,  works  well 
enough  for  the  young,  though  the  intermissions  may  be  most 


MUSCULAR  EXERCISE  AS  A  PROPHYLACTIC       573 

keenly  felt  by  them.  After  the  age  of  thirty  some  form  of 
daily  exercise  should  be  selected  and  adhered  to  ;  and  the 
choice  is  now  varied. 

Horse  exercise,  of  which  Sydenham  held  that  it  was  of  so 
much  value  in  gout  that,  had  it  not  been  long  invented,  its 
inventor  might  have  realized  a  fortune,  is  still  unsur- 
passed ;  but  the  bicycle  now  throws  analogous,  and  some- 
times superior,  advantages  within  the  reach  of  the  larger 
number.  The  more  sedate,  if  heavier,  tricycle  has  long 
been  the  secret  of  health  for  many  a  gouty  subject  physi- 
cally unfit  for  equitation.  A  sharp  walk  up-hill  may  suffice 
to  cause  the  skin  to  act,  but  mere  walking,  especially  on  level 
ground,  fails  to  '  shake  the  liver.'  This  is  one  of  the  boons 
of  riding  a  horse  or  a  tricycle.  The  mechanical  jolting  of 
the  viscera  is  brought  about  passively  and  without  additional 
effort ;  whilst  the  active  methods  of  securing  this  result, 
even  the  use  of  the  skipping-rope,  entail  more  exertion  than 
many  could  attempt. 

All  open-air  exercises  are  much  to  be  preferred  to  the 
various  forms  of  gymnastics  devised  for  home  use  ;  in 
addition  to  their  exhilarating  effect  upon  the  nervous 
system,  they  possess  the  higher  oxygenating  value  attach- 
ing to  rapid  movement  through  space.  Chamber  gymnastics 
offer,  however,  many  advantages ;  they  can  be  varied  so 
as  to  suit  almost  every  degree  of  debility  or  of  articular 
affection  ;  they  save  time  ;  they  are  independent  of  the 
weather ;  and  they  may  be  religiously  performed  as  part 
of  the  toilet,  with  every  facility  at  hand  for  the  warm 
sponging  and  cold  affusion  which  are  the  proper  com- 
plement of  all  forms  of  exercise  accompanied  with  sweat- 
ing. At  any  rate,  any  advantage  gained  may  be  kept  up 
in  this  way,  so  as  to  minimize  the  risk  of  a  gouty  attack 
being  set  up  by  some  unusual  physical  exertion.  Fortified 
by  this  daily  allowance  of  work,  gouty  subjects  will  derive 


574  THE  HYGIENE  OF  THE  FOOT 

greater  benefit  from  a  periodical  visit  to  Angelo's  or  to 
any  of  the  fencing-schools  for  an  assault  with  foils  or  a 
bout  with  single-sticks,  from  a  round  at  the  links,  or,  if 
enjoying  the  advantage  of  residence  in  the  country,  from 
frequent  outings  with  rod  or  gun,  or  from  the  varied 
outdoor  pursuits  of  a  country  life. 

THE  HYGIENE  OF  THE  FOOT. 

Little,  probably,  can  be  done  by  local  measures  to  obviate 
the  tendency  to  a  localization  of  the  gouty  inflammation 
in  the  toe  and  in  other  joints.  Yet  some  attempt  might 
be  made,  with  that  view,  to  place  the  threatened  joint 
under  the  most  favourable  conditions. 

In  ordinary  life  the  movements  of  the  great  toe  are 
always  much  restricted  by  boots  or  shoes  ;  and  too  often 
injurious  pressure  is  exerted  upon  it,  and  upon  other  parts 
of  the  foot.  Both  these  evils  should  be  met.  Passive 
movement  and  massage  to  the  joints  of  the  foot,  and 
particularly  to  that  of  the  great  toe,  would  fulfil  the  first 
indication ;  and  this  forms  part  of  the  treatment  at  some 
of  the  mineral  springs.  Walking  barefooted  or  in  socks, 
and  active  movements  of  the  toes  when  the  foot  is  free 
and  at  rest,  are  also  obvious  means  of  improving  the 
lymphatic  circulation  in  the  fibrous  structures,  and  of 
strengthening  the  joint. 

It  would  be  equally  rash  to  assert  that  the  gouty  in- 
flammation was  provoked  by  the  pressure  of  ill-fitting 
boots,  and  to  entirely  exclude  that  influence  from  its 
aetiology.  Our  obvious  duty  is  to  warn  those  predisposed 
to  gout  against  this  source  of  danger.  In  the  children 
bf  gouty  parents  the  jealous  watchfulness  exercised  during 
infancy  over  the  beautiful  symmetry  of  the  foot  should  not 
be  suspended,  as  too  often  happens,  during  later  childhood, 
or   with   the  advent    of  puberty,  when   an    unintelligent 


MENTAL  WORK  AND  MORAL  INFLUENCES         575 

vanity  too  often  begins  its  destructive  work ;  and  vigilant 
attention  should  be  bestowed  upon  the  timely  supply  of 
well-made  and  hygienic  boots  or  shoes,  to  meet  the  re- 
curring needs  of  the  growing  foot.  As  the  gouty  age 
approaches,,  increasing  care  should  be  given  to  these  im- 
portant details. 


MENTAL   WORK  AND  MORAL  INFLUENCES. 

The  efficacy  of  excessive  mental  application,  of  moral 
shock,  and  of  mental  depression,  in  exciting  a  fit  of  the 
gout  in  those  who  are  confirmed  sufferers,  is  well 
authenticated.  It  may  be  doubted,  however,  whether  a 
tendency  to  gout  can  be  materially  increased  by  mental 
labour  in  itself,  though  Sydenham's  authority  has  given  it 
a  bad  name  :  '  The  same  mischief  follows  the  over-applica- 
tion of  the  mind  to  serious  matters  and  deep  study. 
Melancholy,  so  called,  is  pre-eminently  the  inseparable 
companion  of  gout.  Hence  those  who  are  liable  to  it  are 
so  wont  to  tire  and  overwhelm  the  animal  spirits  by  long 
and  deep  thought,  that  excessive  exertion  of  this  sort,  even 
without  the  artificial  aid  of  reading,  makes  the  proper  pre- 
servation of  the  economy  of  the  body  an  impossibility ; 
for  which  reason  (as  seems  to  me)  gout  rarely  attacks 
fools.  Those  who  choose  may  except  the  present 
writer.' 

A  sharp  distinction  should  be  drawn  between  healthy 
mental  activity  and  the  excessive  and  exclusive  strain 
which  is  too  often  thrown  upon  the  mental  powers.  This, 
like  every  other  exhausting  influence,  favours  the  onset  of 
the  paroxysm,  and  like  any  other  cause  interfering  with 
the  due  exercise  of  the  muscular  functions,  it  must  tend, 
if  other  circumstances  should  co-operate,  to  develop  gout 
in  those  previously  free  from  it. 


576  REST  AND  SLEEP 


Neither  physiology  nor  common  experience  warrant  us 
in  regarding  mental  activity  and  vigorous  cerebral  work 
in  any  other  light  than  that  of  a  tonic  and  vitalizing 
iniluence.  Amongst  the  most  active  and  assiduous  brain- 
workers  we  find  numerous  cases  of  longevity,  and  com- 
monly the  most  healthy  lives.  These  are  almost  in- 
variably instances  of  men  who  have  known  how  to  vary 
their  labours.  We  may  repeat  that  the  best  rest  for 
brain  fatigue  is  muscular  exertion.  Within  the  limits  of 
individual  strength  both  functions  are  conducive  to 
health  and  longevity,  and  both  are  beneficial  from  the 
point  of  view  of  gout :  but  they  must  be  wisely  combined. 
If  the  essential  requirement  of  muscular  activity  is  not 
neglected,  we  agree  with  the  late  Professor  Cantani's 
opinion,  that  mental  work,  free  from  worry,  is  good 
hygiene,  even  for  those  who  may  be  gouty  or  predisposed 
to  gout. 

REST  AND  SLEEP  IN  THE  DAY. 

The  last  of  our  duties  is  one  of  primary  importance.  It 
is,  together  with  food,  the  foundation  of  the  hygienic 
treatment  of  gout  by  exercise. 

Rest  in  the  horizontal  position  is,  in  all  states  of  debility, 
and  especially  at  the  gouty  age,  the  indispensable  adjunct  of 
active  muscular  exertion.  The  latter  can  only  do  good  on 
the  condition  that  the  cardiac  energy  is  economized.  The 
heart  will  gain  power  in  proportion  to  the  additional  rest 
to  which  it  is  entitled  by  hard  work.  The  allowance  of 
rest  must  be  at  first  liberal,  and  the  amount  of  exertion 
very  gradually  increased.  When  the  heart  and  the 
muscles  have  been  trained  to  efficiency  by  careful  manage- 
ment, a  few  minutes'  reclining  at  ftdl  length  will  often  suffice 
to  restore  the  feeling  of  freshness  which  indicates  a  return 
of  fuh  systolic  adequacy. 


SLEEP  AND  REST  IN  BED  577 

A  neglect  of  this  saving  clause  of  rest  for  the  heart 
explains  the  failures  and  the  damage  too  often  observed  as 
a  result  of  a  good  method,  badly  applied.  Independently 
of  any  systematic  exercise,  mid-day  rest  is  often  needed 
by  overworked  subjects,  and  the  best  time  for  taking  it  is 
immediately  before  the  mid-day  meal  or  the  afternoon  tea.  A 
useful  instalment  of  cardiac  rest  is  also  gained  by  men  of 
sedentary  occupations  by  making  a  practice  of  sitting 
when  at  work  with  the  feet  and  legs  supported  in  the 
horizontal  position. 

SLEEP  AND  REST  IN  BED. 

Long  hours  in  bed  are  undesirable  in  chronic  gout  or 
goutiness,  tending  to  relax  when  stimulation  is  wanted, 
and  to  encourage  the  habit  of  dozing,  which  may  destroy 
the  aptitude  for  sound  sleep.  The  boon  of  deep  sleep  is 
one  to  be  jealously  guarded.  Tea  and  coffee  should,  for 
that  reason,  be  avoided  by  most  patients  after  five  o'clock 
in  the  afternoon.  The  best  sleep  is  not  always  that  which 
lasts  the  longest — quality  making  up  for  a  less  duration. 
Adequate  exertion  during  the  day  is  the  means  to  secure 
it.  The  hours  of  sleep  should  not,  however,  be  stinted : 
at  least  seven  hours  are  necessary ;  an  eight  hours'  sleep 
is  ample,  and  this  allowance  should  not  usually  be  exceeded. 

Insomnia,  the  prevailing  cause  of  which  is  dyspepsia, 
may  also  be  induced  by  the  wilful  neglect  of  hygiene. 
The  habit  of  sleep  is  capable  of  cultivation,  but  it  may 
easily  be  lost  by  over-fatigue  of  the  brain  and  late  hours. 
Again,  insomnia  may  be  brought  about  by  excessive  indul- 
gence in  morning  slumbers.  A  rigid  rule  of  early  rising 
soon  restores  in  these  cases  the  capacity  for  sound  sleep. 

Early  risers  need  a  brief  period  of  sleep  in  the  day.  It 
should  be  obtained,  if  possible,  before  lunch.  The  indulgence 
in  a  long  sleep  after  meals  is  strongly  deprecated  in  most 

37 


578  SLEEP  AND  REST  IN  BED 

conditions,  but  particularly  in  gout.  The  habit  of  relative 
activity  after  meals,  though  irksome  to  acquire,  and  not 
suited  to  all,  tends  to  strengthen  the  digestion,  and  to 
safeguard  the  night's  sleep. 

Sydenham  insisted  much  on  the  virtues  of  early  hours : 
*  Next  to  bleeding  and  purging,  nothing  undermines  the 
forces  of  Nature  like  late  hours.  .  .  .  Hence  I  advise 
gouty  patients,  especially  in  winter,  to  go  to  bed  very 
early,  and  to  rise  betimes,  however  much  their  shortened 
slumbers  may  induce  them  to  seek  a  morning's  sleep  by 
lying  in  bed,  the  more  so  as  every  morning  slumber 
subtracts  so  much  from  the  next  night's  rest,  and  so 
does  violence  to  Nature.  Perversely  to  turn  day  into 
night,  and  night  into  day,  is  to  despise  her  prudent 
economy.' 

We  need  not  follow  Sydenham  in  a  discussion  of  the 
relative  value  of  sleep  taken  early  or  late  in  the  course  of 
the  night  whilst  its  duration  remains  the  same — a  subject 
much  complicated  in  modern  times  by  the  introduction  of 
gas  and  of  electric  light.  Dialectics,  in  the  endless  dis- 
cussions on  this  topic,  will  never  prevail  against  the  rules 
of  common-sense.  Health,  which  early  hours  invariably 
promote,  is  wealth  in  itself;  it  may  also  mean  wisdom, 
bearing  out  the  spirit,  if  not  the  letter,  of  the  proverb. 

HABIT  AND  CHANGE. 

'  Chronic  diseases,  always  excepting  those  which  arise 
from  internal  agencies  or  inherited  defects,  are  in  the  main 
dependent  upon  violations  of  physiological  laws.'  '  Return 
to  the  ways  of  physiological  righteousness,  and  you  will  be 
healed.' 

These  words  of  Sir  Andrew  Clark  apply  with  special 
fitness  to  acquired  gout,  which  illustrates  the  influence  of 
habit  in  its  mode  of  production  and  in  the  method  of  its 


HABIT  AND  CHANGE  579 

cure.  The  late  changes  induced  by  inveterate  gout  are 
most  often  incurable ;  but  in  its  slighter  degrees,  and 
before  the  advent  of  senility,  gout  is  sometimes  cured, 
and  it  is  always  capable  of  alleviation.  The  first  requisite 
is  to  put  a  stop  to  the  faulty  habits,  which  by  long  con- 
tinuance have  warped  the  normal  play  of  functions. 
Freed  from  this  pressure,  the  vis  medicatrix  naUircB  re- 
asserts itself,  and  an  upward  tendency  is  established. 
But  hygiene  can  do  more  than  merely  secure  the  condi- 
tions which  least  hamper  Nature.  Her  constructive 
energies  must  be  aided  by  the  slow,  but  steady,  influence 
of  hygienic  habits.  Their  action  becomes  cumulative  if 
kept  up.  Health  must  be  made  a  constant  study,  and 
those  habits  should,  if  possible,  be  acquired  which  are 
conducive  to  vitality.  Reform  cannot  be  introduced 
without  some  effort ;  but  it  becomes  less  laborious  by 
practice,  and  brings  with  it  increasing  capacity  for  en- 
joyment and  chances  of  longevity.  If  life  is  harder, 
faster,  keener  than  it  was,  yet  for  toil  or  for  pleasure 
it  is  perhaps  felt  better  worth  living  than  ever  before, 
and  will  amply  repay  the  cost. 

Strict  observance  of  the  rules  of  hygiene  is  made  easy 
if  they  should  include  sufficient  variety.  Monotony  is 
depressing.  The  stimulating  virtue  of  change  is  perhaps 
nowhere  more  apparent  than  in  connection  with  gout- 
Our  most  potent  hygienic  stimulants,  change  of  air 
and  of  scenery,  are  always  combined  with  a  break  in 
the  routine  of  life ;  and  no  other  measure  can  in  this 
respect  compare  with  foreign  travel.  The  same  prin- 
ciple might,  however,  be  applied  in  many  other  ways. 
The  renovating  influence  of  change  should  never  be  lost 
sight  of,  and  should  be  provided  as  far  as  possible  in  the 
regulation  of  every-day  life. 

This  applies  to  the  majority  of  cases,  but  in  respect  of 


58o     THE  PERSONAL  INDICATION  IN  TREATMENT 


change  and  of  variety,  as  in  everything  else  in  gout,  one 
great  principle  governs  all  others.  Allowance  must  be 
made  for  peculiarities  of  circumstances  and  of  disposition. 
The  proper  treatment  of  gout  is  to  treat  the  patient. 
Whether  in  respect  of  diet,  or  of  stimulants,  or  in  con- 
nection with  exercise  and  change,  no  rigid  rule  can  be 
laid  down  for  general  application,  and  purely  theoretical 
views  should  always  give  way  to  the  practical  indications 
of  the  individual  case. 


INDEX, 


Absorption,  14,  291 
Acidity.       See     Articulations,     Blood, 
Stomach,  Sweat,  Urine 

local  gouty,  297,  305 

lessened  by  sweat,  571 

raised  by  meat,  537 
Acid-lecithin-albumin,  86 
Acne.     See  Gouty  Skin  Diseases 
Africa.     See  Medicinal  Springs 
Air-cure.     See  Hygiene 
Aix.     See  Medicinal  Springs 
Albuminuria.     See  Gouty 
Alcohol.     See  .Etiology,  Diet 
Alkali,  Alkaline.     See  Treatment,  Me- 
dicinal Springs,  Diet 
Alternation  of  symptoms.     See  Gout 
Altitude.     See  Hygiene 
Am61ie  -  les  -  Bains.       See     Medicinal 

Springs 
America,  28.     See  Medicinal  Springs 
Anaemia,  56.     See  Gouty 
Ankylosis,  115 
Aphasia,  245.     See  Gouty 
Apoplexy,  246.     See  Gouty 
Arfewdson,  384  [52 

Arthritis,   artificially   produced  (Haig), 
Anhritism,  10,  67 
Articular  gout,  194  \ 

aetiology,  196 
Articulations,  lesions,  110-120,  194 

chemical  reaction  of,  53,  ig6,  305 

of  great  toe,  194,  195 

order  of  implication,  116,  195,  196 
Asparagus.     See  Vegetables 
Assimilation,  14,  107 
Atheroma,  124-127 

theories  of,  126 

Barclay,  59 
Bartels,  103 
Begbie,  248 
Bence  Jones,  71,  133 
Beneke,  15,  298,  313.  379 
Biesenthal's  experiments,  508 
Blake,  Dr.  Edward,  562,  563 
Bleibtreu,  533 


Blisters.     See  Treatment 
Blood  corpuscles,  59 

reaction,  570 

acid  phase  of,  94,  367 

serum,  69 
Bone,  IT4,  115 

Bouchard,  15,  92,  163,  269,  279 
Bradford,  Dr.,  93 
Bright's  disease,  aetiology,  459 
Bruce,  Dr.  Mitchell,  229,  347,  397,  404 
Brunton,  Dr.  Lauder,  375,  389,  396 
Brushfield,  Dr.  T. ,  408 
Bursitis,  119 
Busquet,  534 
Buzzard,  Dr.,  65 

Cachexia,  ij.     See  Gouty 

alkaline,  369 
Calcium.      See   Treatment,    Medi:inal 
Springs 

oxalate,  56,  121 

urate,  121 
Calculi,  biliary,  139 

in  relation  to  hard  water,  494 

mortality  from,  495 

urinary,  137 
Camerer,  95 
Cameron,  104 

Canada,  28.     See  Medicinal  Springs 
Cancer,  163 
Cantani,  28,  576 
Cartilage,  lesions  of,  112114 
Cazalis,  Dr.  H.,  561,  568 
Charcot,  65,  67 

Ley  den  crystals,  211 
Chemiotaxis,  108,  150,  288 
Chittenden,  104 
Christison,  169 
Cider,  559 

Clark,  Sir  Andrew,  I2r,  130,  578 
Colchicine,  347,  363 
Colchicum,  346-361 

action,  anodyne,  352,  353 
hepatic,  352 
specific,  351 
vascular,  352354 


582 


INDEX 


Colchicnm,  action  on  uric  acid,  355 

contrast  with  digitalis  and  morphia, 

353 

Garrod's  results,  358 

history  of,  346 

Home's  experiments,  348 

Lecorch^'s  results,  349 

objections  to,  357,  358 
Concretions.     See  Uric  Acid,    Urates, 

Tophi 
Connective  tissues  and  gout,  568 
Contrex^ville.     See  Medicinal  Springs 
Convulsing  urinary  principle,  279 
Coupland,  Dr.  Sydney,  124 
Cullen,  2,  32,  64 
Curability  of  gout,  327 

Dapper,  100,  533 

Davy,  Mr.  R.,  559 

Debout  d'Estr^es,  Dr.,  221 

Deformity  of  hands,  117,  119 

Deposits.     See  Uric  Acid,  Urates 

Diabetes,  164-166 

Diathesis,  7 

Dickinson,  Dr.  W.  H.,  134-136,  214 

Diet,  519-535 

alcoholic  beverages,  524,  555-559 

ale  and  stout,  559 

cider,  559 

percentage  in  spirits  and  wines, 

557 
wmes,  557,  558 

constipation,  524 

dogmatism,  523 

dyspepsia,  524 

fasts,  548 

food,    albuminoid   percentages   in, 
526 
constituents,  525-528 
and  leucocytosis,  531-535 
quantity  and  selection,  546 

fruit,  552,  553 

habit,  548 

in  gout,  acute,  417 
chronic,  551 

in  goutiness,  551 

in  gouty  glycosuria,  457,  551 
indigestion,  550 

meat,  acidity  raised  by,  537 
butcher's  and  white,  551 
consumption    by   the   masses, 

520 
leucomqines  and  uric  acid,  524 
uric  acid  percentage  in,  538 

milk,  exclusive,  457,  541,  550,  551, 

554.  556 
rules,  549 

simplicity  and  variety  in,  545,  547 
vegetables  and  fruit,  529 

uric    acid  relatively   increased 

by,  537 
various,  552 
egetarianism,  536-541 
disapproved,  541 


Diet,  vegetarian,  value  of,  541,  544 
water  and  mineral  salts  in,  530 
Duckworth,  Sir  D.,  65, 113,  137, 167, 179 
Dunlop,  Dr.  C,  89 
Dupuytren's  contraction,  119 

Ebstein,  34,  46-48.  60,  62,  91-93,  113. 

114,  287,  297,  508,  528 
Eczema,  239.     See  (jouty 
Emphysema.     See  Gouty 
Empiricism,  321 
Epilepsy,  168 
Exercise.     See  Hygiene 
Exophthalmic  goitre,  231 

Feliziani,  87 

Fencing,  574 

Food,  unearned,  523.     See  Diet 

Fourcroy,  122 

Fox,  Wilson,  212 

Frerichs,  97 

Fruit.     See  Diet 

Gairdner,  Professor,  58,  64 
Galland-Gleize,  Dr. ,  497 
Galtier-Boissiere,  368,  376 
Garrod,  Dr.  A.,  154,  156,  159,  513,  514 
Garrod,  Sir  A.,  136,  169,  173,  327,  350, 
376,  438.     See  Gout,  Uric  Acid,  etc. 
Gastritis.     See  Gouty 
Geography  of  gout,  28 
Gibbons,  Dr.,  84 
Gicht-wasser,  507,  510 
Glycocine,  40 
Golf,  574 
Gout,  astiological  factors  in,  195 

age,  26,  27,  128 

alcohol,  555-559 

civilization,  300 

climate,  567 

diet,  30 

faulty  digestion,  298 

metabolism,  298 

nutrition,  299 

heredity,  277,  304 

lead,  170,  174 

liver.     See  Liver 

mental  influence,  30 

nerve  energy  misdirected,  300, 
301,  302-304 

oxidation  depressed,  298 

paralysis,  156,  245 

race,  29 

season,  28,  197 

sex-,  27,  275 

social  position,  27 

temperature,  29 

traumatism,  256 
affinities  of,  154 
alternations,  hereditary,  26 

of  symptoms,  207 
attenuations  of,  18,  20,  21,  521 
chemical  factors  in,  78 
chemistry  of,  69 


INDEX 


583 


Gout,  contemporary,  19 
criterion  of,  206 
definition,  Garrod's,  2 
forms  of,  abarticular,  20 

acquired,  20 

chalky,  200 

chronic,  crippling,  198,  199 
deforming,  no,  201 

declared,  7 

flying,  262 

general,  6 

hereditary,  25 

incomplete,  17 

lead-,  169-179 

local,  6 

metastatic,  182,  217-225,  262 

visceral,  260,  261 

wandering,  -262 
in  hemiplegia,  156,  245 
lead-,  169-179,  284-286 

aetiology,  170-174 

arterial  tension  in,  178 

influence   on    various   organs, 
177,  179 

kidney  lesions,  172.  173 

leucocytosis  in,  178 

neuritis,  178 

uric  acid  excretion  in,  172 
liver  in,  151 
poor  man's,  94 
prevalence,  18 
primary  renal,  144 
stages  of,  acute  arthritic,  137 

chronic  arthritic,  200 

latent  arthritic,  184 

prearthritic,  16,  183,  185 

progress  of,  197 

quiet  arthritic,  184 
theories  of,  chemical,  39,  149, 
modified,  49 
of  lessened  alkalinity,'  44 

of  connective  tissue   engorge- 
ment, 570 

of  faulty  innervation,  37 
nutrition,  36 

Garrod's,  43 

of  hepatic  inadequacy,  49 

histogenous,  58,  59 

humoralistic,  31 

of    irritation    by    redissolving 
urates,  45 

of  joint  centre,  51,  65,  304 

of  lithgsmia,  32 

of  medullary  influence  on  liver, 

SI 
of  necrosis  of  tissues,  46,  62 
nervous,  32,  37,  64,  300-306 

reflex,  60 
neural,  68,  254-261,  307,  308, 

319,  320 
neuritis,  307 
neuro-humoral,  38 
neurosis,  primary,  66 
Ralfe's,  44 


Gout,  theory  of  renal  block,  35,  283 

renal  and   uric   acid,    38,    39, 
2S2,  287 

solidist,  31 

of  tissue  degeneration,  60 

toxic  (of  arthritis),  305 

trophic,  290 

of    tropho-neurosis,    65,    308, 
309,  320 

of  uric  acid,  33 

mechanical,  34,  306 
mechanical  and  toxic,  34 
toxic,  34,  52,  305 
and  vascular  tension,  51 

Wade's.     See  Theories,  neural 
urology,  260 
Goutiness,  7,  16,  322 
acidity  of,  297 
changes  in,  312 
contemporary,  19 
curability  of,  315 
nervous  factor  in,  302,  303,  320 
Gouty  acidity,  297,  313,  371 

acute  arthritis,  186-193,  ^58 

cBtiology,    nervous,    304,    319, 
320 

curative  effect  of,  186 

diagnosis,  192 

duration,  193 

lesions,  193 
albuminuria,  144,  146,  182,  227 
anaemia,  56,  204 
angina,  230,  273 

pseudo-,  230 
aphasia,  246 
apoplexy,  245 
asthma,  211,  211 
atheroma,  124,  127,  228 
biliousness,  152 
bladder,  irritable,  219 
bronchial  irritability,  211 
bronchitis,  133,  209-211 
cachexia,  5,  17,  no,  133,  163,  199, 
202,  203 

tuberculosis  in,  133,  204 
cerebral  affections,  245 

congestion,  248 

neuroses,  247 

softening,  245 
clinical  types,  181,  182 
colic,  219 
constitutions,  180 
cramp,  253 
cystitis,  220 
diabetes,  182,  512 
diathesis,  7 

dyspepsia,  203,  215,  216 
ear  affections,  243 
emphysema,  134,  212 
encephalopathy,  246,  273 
enteritis,  217,  218 
erysipelas,  131 
eye  affections,  242 
gall-stones  in  the,  225 


584 


INDEX 


Gouty,  gangrene  in  the,  131 
gastritis,  217,  218 
gastro-enteritis,  217,  218 
Graves'  disease,  231 
the  hair  in  the,  238 
haemoptysis,  213 
haemorrhage  in  the,  125,  130,  134, 

162,  213,  220 
haemorrhoids  in  the,  234 
headache,  252 
heart  and  bloodvessel  lesions,  123, 

124 
heart,  '  functional,'  22B,  229 

hurry,  229 

irregularity,  229 

neuroses,  231 

slow  action,  230 
hepatic  affections,    138,    139,   151, 
223-225 

inadequacy,  152 
heredity,  277 
hypersemia  and  ischoemia,  252 

reflex,  274 
idiosyncrasy,  263-266,  276 
immunity,  female,  275 
insanity,  247 
insomnia,  247 

irritability,  207,  217,  266,  270. 
jaundice,  226 
kidney,  134-137,  203-206 

early  changes  in,  146,  14B 
laryngitis,  133,  207,  210 
lesions  of  digits,  fasciae,   tendons, 

201 
lithsgmia,  152 
lumbago,  252 
lymphangitis,  130,  131 
medullary  affections,  249 
megrim,  252 
metastasis,  182,  217-115,  262 

mechanism  of,  267-271,  320 
myalgias,  252 
nails,  237,  312 
nervous  irritability,  301 
neuralgise,  140,  244,  250,  251 
neuritis,  244,  251,  257 
neuroses,  visceral,  249 
orchitis,  220 
ovaritis,  221 
pain,  190 
paralyses,  140 
paraplegia,  248 
perineuritis,  140 
pharyngitis,  215 
phlegmasia,  233 
pneumonia,  213 
premonitions,  189 
pulmonary  congestion,  213 
renal  haemorrhage,  220 

toxjemia,  204 
rigor  in  acute  attack,  187 
sciatica,  250 
skin  in  the,  235,  236 
skin  diseases,  237-241 


Gouty  spinal  cord  affections,  248 

suppuration  in  the,  131 

symptoms,  190-192 

sweat  in  the,  237 

tenderness,  254-256 

tongue,  214 

tonsillitis,  215 

tracheitis,  210 

urethritis,  220 

uterine  catarrh,  221 

vascular  reactions,  271 

veins,  varicose,  234 

vertigo,  247 

visceral  affections,  205,  273,  320 
Granville,   Dr.    J.    Mortimer,    26,    292, 

416,  437,  537,  551,  558 
Gravel,  83,  187 
Graves,  140 
Greek  language,  14 
Greenfield,  Professor  W.  S.,  137 
Guaiacum.     See  Treatment 

Habit,  315 

in  cell  life,  314 
Haemophilia,  167 
Haemorrhage,  cerebral,  125,  T30 

into  joints,  120 

pulmonary,  130 

tendency  to,  167 
Haig,   Dr.  A.,   51-57,  91-93,   155,  290, 

399.  537.  538,  570 
H  ard  water.    See  Calcareous  Medicinal 

Springs 
Harley,  Dr.  V.,  84,  87,  103-107,  463 
Hayem,  Professor,  132 
Heberden's  nodes,  115 
Heel,  toe,  etc.     See  Gouty  Tenderness 
Henle,  64 

Hepatic  disorders.     See  Gouty 
Heredity.       See    Gout,    Gravel,    Uric 

Acid,  etc. 
Herpes  zoster,  250 
Herpetism,  10 
Hindoos,  86 
Hirschfeld,  533 
Hoffman,  Dr.  A.  H.,  28 
Holland,  Sir  Henry,  359,  436 
HoUis,  Dr.  Ainslie,  126 
Horbaczewski,  36,  48,    loi,   107,    288, 

3T4,  531,  532 
Hutchinson,  Mr.  Jonathan,  67,  168 
Hutchison,  Dr.  Robert,  570 
Hydrotherapy.     See  Hygiene 
Hygiene,  562-579 
air-cure,  562 
altitude,  565 
athletics,  562 
baths,  cold  affusion,  567 

Turkish,  567 
early  hours,  578 
exercise,  567 

daily,  not  weekly,  572 
neglected  in  middle  life,  572 
varieties  of,  573,  574 


INDEX 


585 


Hygiene,  habits  good  and  faulty,  579 
horizontal  posture,  562 
longevity,  576 
of  foot,  574 
oxygen,  562 
perspiration,  567,  570 
radical  treatment  by,  566 
respiratory  therapeutics,  562 
St.  Moritz,  565 
sea-air,  565 

sleep  and  insomnia,  577 
study,  objections  to,  575 

tonic  effect  of,  576 
summer,  perpetual,  564 
sunlight  cure,  563 
variety,  influence  of,  579 
Veldes,  564 

Idiosyncrasy  and  intolerance  for  foods, 

542,  547 
India,  28 

Iodides  in  albuminuria,  437 
Iodine,  416 
Italy,  28 

Johnson,  Sir  George,  134 
Joints.     See  Articulations 

Kidney.     See  Gouty,  Renal 

Laennec,  210 

Lancereaux,  124,  135  [107 

Latham,  Professsor  P.  W.,  49,  50,  106, 

Lay  cock,  23,  58,  180 

Lead.     See  Gout 

Lecorche,  145,  398,  401 

Legg,  Dr.  Wickham,  167 

Lehmann,  36,  536 

Leucocytosis  and  uric  acid,  531-535 

Leucomaines  and  ptomaines,  543     • 

Levison,  135,  145,  535 

Liebermann,  86 

Lipping,  112,  115 

Lith^mia,  relation  to  gout,  294-296 

Lithium  salts  toxic,  509 

Liveing,  Dr.  E.,  65 

Liver.     See  Gouty:  Hepatic 
in  aetiology,  292,  315 
as  blood  elaborator,  293,  294 

Lucian's  satire,  325 

Lymphstasis,  570 

Lysidin,  392-394.     See  Treatment 

Magnesium.     See  Treatment 

Maruss,  100,  534 

Materia  peccans,  2 

Meat  consumption.     See  Diet 

Mead,  541 

Medicinal  springs.     See  Springs 

Meissner,  106 

Meninges,  139 

Menstruation,  56 

Metibolism,  12,  14,  54  56 

Minkowski,  106 


Mixture  of  foods,  544,  547 

Moore,   Dr.    Norman,    116,    130,   133, 

137 
Murchison,  32,  49,  138,  226,  294,  315 
Musgrave,  23,  140,  169,  219 

Narcotic  toxic  urinary  principle,  279 
Nervous  system  in  gout,  139,  140.     See 

Gout,  Gouty 
Neuroses,  37.     See  Gouty 
Nodules,  subcutaneous,  241 
Nomenclature,  i,  8 
Nutrition,  perverted,  13 

CEdema,  angioneurotic,  241 
Ollivier,  139,  140,  248 
Omnivorous  character,  544 
Ord,  Dr.  W.  M.,  60,  61,  72,  160 
Osier,  Professor  W.,  125 
Osteitis.     See  Bone 
Oxalic  acid,  87-89 
Oxaluria,  88 

Paget,  Sir  James,  137,  161 
Pancreatico-duodenal  dyspepsia,  292 
Parkes,  Dr.  E.,  58,  loi,  114,  317 
Parry,  169 

Parsees,  28,  540,  567 
Peiper,  Dr.,  54 
Penzoldt,  103 

Pfeiffer,  45,  48,  83,  87,  91,  95 
Phagocytosis,  108 
Pharyngitis.     See  Gouty 
Phthisis  in  gout,  161,  162 
Pidoux,  10,  57 

Piperazine,  loi,  508.     See  Treatment 
Plethora,  315 

Plumbism.     See  Gout :  Lead 
Pneumonia.     See  Gouty 
Pollock,  Dr.  James  E. ,  161 
Pollock,  Mr.  George,  264 
Port  wine.     See  Diet  :  Wines 
Potassium.     See  Treatment 
chromate  injections,  63 
Prevention.     See  Treatment,  Hygiene 
Prognosis,  316 

Prurigo.     See  Gouty  Skin  Diseases 
Psoriasis.     See  Gouty  Skin  Diseases 
Puberty,  56 

Pulse.     See  Gouty  Heart 
Pye  Smith,  Dr.  P.  H.,  20 

Quadriurates,  71,  72 

Ralfe,  Dr.  C.  H.,  297 
Ranke,  H.,  106 

Reaction.      See  Blood,  Joints,  Sweat 
Renal  diseases.      See    Gouty    Kidney, 
Calculi 

colic,  adult,  84 
infantile,  85 

inadequacy,  93 
Renaut,  568 
Rendu,  113,  222,  305,  307,  380 


5^ 


INDEX 


Resistance,  lessened,  15 

Retention    of   uric  acid.      See    Gout, 

Theories  of 
Retrocedence.     See  Gouty  Metastasis 
Rheumatism  and  gout,  52,  154-158 
Rheumatoid  arthritis,  159-161 
Rieken,  167 
Roberts,    Sir  W.,    69,    288,   297,   416. 

See  Gout  :  Chemistry,  Theories 
Roose,  Dr.  Robson,  138 

Salicylates.     See  Treatment 
Saline  solution  (Roberts'),  74 
Salomon,  47,  93 

Saturnine  gout.     See  Gout :  Lead 
Sauvages,  169 
Scepticism,  ancient,  325 
modern,  326 

Sydenham's,  Cullen's,  327 
Scheeie,  2,  39 
Schroeder,  106 
Schultze,  100,  103,  533 
Scotland,  gout  rare  in,  28 
Scrofula  and  gout,  162 
Sea-air.     See  Hygiene 
Secretion,  internal,  108 
S6e,  Germain,  397 
Semmola,  459 
Serum,  69 

artificial,  69 
Sherry.     See  Diet :  Wines 
Skin  diseases.     See  Gouty 

infiltration,  121 
Sleep,  sleeplessness.     See  Hygiene 
Sodium.      See  Treatment :    Medicinal 
Springs 
salts,  percentage  in  tissues,  78 
Spas.     See  Springs,  Medicinal 
Special  sense  organs,  242,  243 
Spencer  Wells,  Sir,  22,  23 
Springs,  medicinal,  classification,  480- 
484 
American,  484,  485 
British,  512-518 
Canadian,  486 
New  Zealand,  486,  487 
alkaline,  simple,  481 
calcareous,  494-497 

behaviour       of       calcium 

towards  tissues,  495 
Ftirst's  experiments,  496 
hard  water  in  relation  to 

calculus,  494 
solvent  power  for  uric  acid, 
4q6 
chalybeate,  484 

muriated  and  brine  baths,  481, 
498-504 

increase  the  tolerance  for 
sodium  bicarbonate,  499 
indications  for,  500 
sodium  chloride  in,  501 
in   gout   and    gravel, 
502-504 


Springs,  medicinal,  classification  : 
sodic  carbonated,  505-510 

chemical    objections 

(Roberts'),  506 
empirical  reputation,  507 
value  of,  510 
Wiesbaden  artificial  water, 

507-510 
sulphated,  493,  514 
sulphurous,  483,  513,  517 
thermal,  indifferent,  480,  512- 
514 
general  advantages  of,  489 

indications  for,  in   gout,  491, 
5II-51C8 
in  diabetes,  512,  518 
individual  spas :  Aix-les- Bains,  445, 

477.  483 

Aix-la-Chapelle,  384,  477,  483, 
Alexisbad,  484  [500 

Allevard,  483 
Ara61ie-les-Bains,  483 
Ashby-de-la-Zouch,  514 
Assmanshausen,  482,  496 
Aulus,  468 
Aussee,  481 
1  Baden,  483 

Baden-Baden,  384,  481 

Bagneres,  483 

Bareges,  483 

Bath,  477,  480,  500,  512,  513, 

515.  517.  518 
Bilin,  384,  482 
Bourbonne-les-Bains,  481 
Brides-les-Bains,  482,  493 
Builth,  484,  513 
Bussang,  484 
Buxton,    468,   476,    480,    512, 

513,  515,  517,  518 
Capvern,  390,  468,  483 
Carlsbad,   384,   391,  468,  482, 

493,  512,  514,  517,  518 
Cauterets,  470,  483 
Challes,  483 

Cheltenham,  468,  483,  513-517 
Clifton,  512 
Contrex^ville,    390,   419,    463, 

468,  483,  495,  497,  512,  517. 

S18 
Dinsdale-on-Tees,  484 
Driburg,  483,  484 
Droitwich,  481,  514-516 
Eaux-Bonnes,  470,  483 
Eaux-Chaudes,  470,  483 
Eilsen,  483 

Ems,  384,  470,  482,  487,  500 
Enghien,  483 
Evian,  483 

Fachingen,  482,  487,  496,  510 
Flitwick,  484 
Gastein,  477 
Hammam  R'lhra,  480 
Harrogate,  470,  476,  477,  500, 

513,  514,  516 


INDEX 


587 


Springs,  medicinal ;  individual  spas  : 
Harzburg,  481 
Helouan,  483 
Homburg,  468,  481,  500,  514, 

S17 
Ischl,  481 
Kissingen,  384,  468,  481,  500, 

514.  S'^7 
Kreuznach,  384,  481 
La  Bourboule,  482 
Leamington,    476,    487,    500, 

514,  516-518 
Levico,  484,  500 
Lisdoonvarna,  484,  513      [518 
Llandrindod,    476,    484,    513- 
Llangammarch      Wells,     514, 
Llanwriyd,  513 

Malvern,  512  [518 

Marienbad,  384,  391,  468,  482, 

493.  517 
Martigny,  483 
Matlock,  512 
Mehadia,  483 
Meinberg,  483 
Moffat,  484,  513,  515 
Mont  Dore  471 
Muskau,  484 
Nantvvich,  514 
Nauheim,  476,  481,  499 
N^ris,  477 
Nenndorf,  483 

Neuenahr,  419,  470,  512,  518 
Orezza,  484 
Panticosa,  483 
Parad,  484 
Plombieres,  477 
Pougues,  390,  468 
Puriri,  487 
Pyrmont,  484 

Ragatz,  477,  480  ■      • 

Ratzes,  484 
Rehme,  481 
Reichenhall,  481 
Rheinfelden,  481 
Roncegno,  484 
Royat,  468,  482 
St.  Honore,  483 
St.  Moritz,  471,  484,  565 
St.  Nectaire,  468 
St.  Sauveur,  483 
Salins-Moutiers,  514 
Saltburn,  514 
Salzbrunn,  482 
Salzschlirf,  482,  496 
Schlangenbad,  480 
Schwalbach,  a.84 
Soden,  470,  514 
Spa,  484 
Stafford,  514 

Strathpeffer,  484,  513,  515 
Tarasp,  483 
Teplitz,  384 
Tunbridge    Wells,    484,    512, 

5^4 


Springs,  medicinal ;  individual  spas  : 
Uriage,  483 

Vals,  481,  506,  510,  517 
Veldes,  563,  564 
Vichy,  384,  481,  495,  506,  510, 

512,  517,  518 
Vittel,  390,  419,  463,  468,  483, 

495.  497.  512,  517,  518 
Weilbach,  483 
Wiesbaden,  468,  481,  496,  500, 

506,  510,  514,  517 
Wildbad,  477,  480 
Wildungen,  483,  496 
Woodhall  Spa,  481,  514-517, 
.Stadthagen,  103,  533 
Stahl,  32,  64 

Storck,  346  [1T9 

Suppuration    of   bursas,   joints,    tophi, 
Sweat,  237.     See  Hygiene 
reaction  of,  570 
uric  acid  and  urea  in,  237 
Synovia,  reaction  of,  118 

Temperament,  29 

Tennant  and  Pearson,  122,  368 

Thread  test,  39 

Todd,  169,  357,  358 

Tongue  in  gout,  214 

Tophi,  93,  94,  201 

composition  of,  121 
disappearance  of,  91 
evacuation  of,  120 
reagents  for,  122 
To.xicity  of  salts,  Bouchard  and  Tapret's 

table,  378 
Treatment,  alkaline,  343,  364 
as  an  alterative,  374 
failure  of,  372 

influence  on  metabolism,  382 
intermittent  use,  383 
rationale  of,  373 
stimulant    to     mucous    mem- 
brane, 375 
ammonium  salts,  387 
arsenical,  405,  439,  442 
benzoic,  402,  403 
bleeding,  341 
blistering,  422,  445 
calcium,  389,  390.     See  Calcium 
colchicum.     See  Colchicum 
administration  of,  360 
indications  of,  359,  361 
toxic  effects,  362 
diaphoretic,  341 
diuretic,  341 
emetic,  339 
evacuant,  339 
guaiacum,  407 

as  a  prophylactic,  438 
hepatic,  340 
-     hot  baths,  432 
hot  water,  432 
ice,  424,  425 
idiosyncrasies,  330 


588 


INDEX 


Treatment,  indications,  333,  334,  336 
iodine,  406 
iron,  408,  441 
lithium,  385,  386 
magnesium,  399,  391 
mercury,  404,  439 
neutralizing,  343 
organic  alkaline  solvents,  343,  366, 

392-394,  462 
patient's  view  of,  328,  329 
physicians  under,  329 
piperazine.  See  Treatment:  Organic 

alkaline  solvents 
potassium,  376-378 

Garrod's  experiments  with,  376 
toxicity  of,  372,  377,  379 
preventive,  prophylactic,  332,  338, 

344.  561 

in  children,  561 
purgative,  339,  413,  414 
salicylate,  365,  395-401 
serpentary  as  a  prophylactic,  441 
sodium,    379-383,     505-512.       See 
Springs,  Medicinal 

chloride,  380 

equilibrium,  381 
hepatic  action  of,  381 
specifics,  357,  368,  416,  441 
strychnine,  408 
sulphur,  405,  438 
Sydenham's  electuary,  409 
tonics,  407-409,  440,  441 
topical,  334,  344 

applications,  422,  423,  445 
Treatment  of  acute  gout,  412 

by  alkalies,  416 

bycolchicum,  414-416 

by  iodine,  416 

by  local  depletion,  421 

local,  419-425 
of  cardiac  affections,  473-476 

by  rest,  exercise,  cardiac  tonics, 

473 

by  saline  baths,  473 
of  chronic  gout,  426-437 

by  alkalies,  433 

by  benzoates,  435 

by  colchicum,  436 

by  climate  and  diet,  429 

by  guaiacum,  43,  438 

by  iodine,  437 

by  laxatives,  430 

by  preventives,  428 

by  salicylates,  435 

local,  443 

by  douche,  444 

by  electrolysis,  446 

local  solvent,  446 

by     passive     movements, 

444.  445 
surgical,  446,  447 
of  diabetes  and  glycosuria,  457 

by  medicinal  springs,  459,  512, 


Treatment  of  gastric  catarrh,  466,  467 
of  gastralgia,  468 
of  gastro-intestinal  catarrh,  468 
of  goutiness,  453-478 
of  gravel,  461-464 
of    hepatic    congestive     disorders, 

454-459 

biliary  catarrh,  456 
of  kidney  affections,  459 

by  alkalies,  460 

by  flushing,  460 
of  metastatic  visceral  affections,  448- 

452 
anginal,  450 
cardio-pulmonary,  450 
cerebral  congestive,  451 

paralytic,  452 
gastritis,  450 
gastro-enteritis,  448,  449 
of  myalgise,  478 
of  neuralgias,  476,  477 
of  plethoric  gout,  balnear,  511 
of  respiratory  affections,  469,  470 
hsemoptysis  in   gouty  emphy- 
sema, 472 
Trousseau,  212,  369 

Urates,  biurate,  quadriurate,  71,  72 
sodium  biurate,  70 
in  blood,  82 
crystals,  irritating,  91 
deposits  in  acute  gout,  312 
articular,  289 
in  bronchi,  208,  209 
in  cartilage,  112,  113 
in  heart  and  valves,  124 
in  kidney,  135,  137 
in  larynx  and  bronchi,  133, 

208,  209 
in  meninges,  139 
in  muscles,  140 
in  nerves,  140,  306 
in  periarticular  tissues,  118 
in  pharynx,  132 
in  veins,  128 
in  villi,  132 

not  proving  previous  arth- 
ritis, 81 
tissues  liable  to,  81 
gelatinous,  72 
insolubility,  91 
maturation,  73,  77 

influenced    by   concentra- 
tion, 75 
salines,  75 
necrosis  due  to,  93 
precipitation,  78,  Bi 

influenced    by   concentra- 
tion, 80 
by  dehydration,  80 
by  excess,  80 
by  sodium,  82 
by  synovia,  79 
in  kidneys,  83 


INDEX 


589 


Urates  :    sodium  biurate,  precipitation 
in  various  tissues,  82 
pricking  pains  from,  81 
re-solution,  81 
saturation  withi,  81,  83,  91 
solubility,  74 
solution,  81 
solvents,  74 
toxicity,  91,  92 
Ure,  368,  384 

Urea  decreased  by  exercise,  570 
formation,  50 
increased  by  meat,  536 
not  toxic,  93,  269 
ratio  to  uric  acid,  53,  98 
Uric  acid,  accumulation,  16,  93 
in  blood,  53,  54,  69,  93,  200 
calculi.     See  Calculi 
derivation,  98,  105 

from  action  of  drugs,  102 
from  leucocytosis,  102,  103 
from  nuclein,  loi 

injections,  103 
from  tissues,  314 
discovery,  2,  122 

effects  of  diet  and  beverage,  99,  100 
excess,  test  for,  in  urine,  87 

in  various  diseases,  57,  99,  104 
excretion,  40 

amount  of,  95 

diminished  in  gout,  96 
varying  with  age,  95,  104 
influence  of  leucocytosis,  531- 
of  lead  gout,  172  [535 

of  metabolism  in  general, 

535 
of  vegetarianism  and  meat, 

536-542 
as  a  vestigial  function,  148,  149 
filter,  46,  87 
formation,  50,  53 

gravel,  influence  of  salt  and  sugar, 
462,  463 

of  meats  and  alkalies,  464 


Uric  acid,  gravel,  influence  of  acid  and 

alkaline  tide,  464 
in  fever,  55 

influence  on  metabolism,  54,  55 
injections,  62,  91 

excreted  as  urea,  92 
necrosis  from,  92,  93  [305 

one  of  many  products  in  gout,  141, 
oscillations,  99,  145 
oxidation  theory,  97 
pathology,  90 
precipitation,  71 

mechanism  of,  85 
retention,  94 
salts  of,  70 

seat  of  production,  105-109 
sediment,  71 
state  in  blood,  288 
synthetically  produced,  107 
theories  of,  142,  143 
toxicity  of,  90,  269 

on  nerves,  92 

on  vessels,  92 
vicissitudes  of  (Haig),  54 
Uricacidcemia,  56 

in  lead-poisoning,  172,  173 
Urine,  toxic  principles  in,  279,  280 
Urology  of  gout,  295  [Diseases 

Urticaria,     241.         See     Gouty    Skin 

Vegetarianism,  54,  536.     See  Diet 
Veins,  128,  129.     See  Gouty 
Virchow,  Prof.  R.,  133 
Visceral  crises,  37 

Wade,  Sir  W. ,  68,  140,  254-261 
Wilks,  Dr.,  248 
Wohler,  97 
Wollaston,  2,  33,  39 
Wynne,  Dr.  E.  T.,  113 

Yeo,  Dr.  J.  Burney,  416,  437,  558 

Zalesky,  105,  106 


FINIS. 


Bauliere,  TindaH  &  Cox,  20  and  21,  King  William  Street,  Strand 


ERRATA. 

For  "  Chemotaxis,"  pp.  io8,  150,  288,  read'-''  Chemiotaxis." 
„     "  Veldis,"  pp.  563,  564,  read  "  Veldes." 


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